Basic Information
| Provider Information | |||||||||
| NPI: | 1437267663 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | AGAHTEHRANI | ||||||||
| FirstName: | ABDOLREZA | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 950202 | ||||||||
| Address2: | |||||||||
| City: | LOUISVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 402950202 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5025889490 | ||||||||
| FaxNumber: | 5022725116 | ||||||||
| Practice Location | |||||||||
| Address1: | 6420 DUTCHMANS PKWY | ||||||||
| Address2: | STE 200 | ||||||||
| City: | LOUISVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 402053372 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5028918300 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/28/2006 | ||||||||
| LastUpdateDate: | 09/17/2014 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RI0011X | 43033 | KY | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Interventional Cardiology |
ID Information
| ID | Type | State | Issuer | Description | 000000635481 | 01 | ANTHEM | OTHER | 50031143 | 01 | KY | PASSPORT & PASSPORT ADVTG - NCVA | OTHER | 7100045440 | 05 | KY | MEDICAID | P00893011 | 01 | KY | RAILROAD MEDICARE - NCVA | OTHER | 3737980000 | 01 | PASSPORT ADVANTAGE | OTHER | 000000693017 | 01 | KY | ANTHEM - NCVA | OTHER | 201044560 | 05 | IN | MEDICAID | 50025829 | 01 | PASSPORT | OTHER | 000057058W | 01 | KY | HUMANA - NCVA | OTHER |