Basic Information
| Provider Information | |||||||||
| NPI: | 1760480453 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KAKAKHEL | ||||||||
| FirstName: | MASROOR | ||||||||
| MiddleName: | U | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2930 11TH AVE | ||||||||
| Address2: | |||||||||
| City: | EVANS | ||||||||
| State: | CO | ||||||||
| PostalCode: | 806201011 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9703539403 | ||||||||
| FaxNumber: | 9703539906 | ||||||||
| Practice Location | |||||||||
| Address1: | 100 N 11TH AVE | ||||||||
| Address2: | |||||||||
| City: | GREELEY | ||||||||
| State: | CO | ||||||||
| PostalCode: | 806312011 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9703528898 | ||||||||
| FaxNumber: | 9703517075 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/07/2005 | ||||||||
| LastUpdateDate: | 01/22/2013 | ||||||||
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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 | 208000000X | 37532 | CO | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 11133741 | 05 | CO | MEDICAID |