Basic Information
| Provider Information | |||||||||
| NPI: | 1770558496 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | THANAWALLA | ||||||||
| FirstName: | FARID | ||||||||
| MiddleName: | ABDULREHMAN | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 10700 E GEDDES AVE | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | ENGLEWOOD | ||||||||
| State: | CO | ||||||||
| PostalCode: | 801123800 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3037619190 | ||||||||
| FaxNumber: | 7208744462 | ||||||||
| Practice Location | |||||||||
| Address1: | 10700 E GEDDES AVE | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | ENGLEWOOD | ||||||||
| State: | CO | ||||||||
| PostalCode: | 801123800 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3037619190 | ||||||||
| FaxNumber: | 7208744462 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/17/2006 | ||||||||
| LastUpdateDate: | 04/07/2017 | ||||||||
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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 | 2085R0202X | 217086 | MA | N | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085R0204X | 217086 | MA | N | Allopathic & Osteopathic Physicians | Radiology | Vascular & Interventional Radiology | 2085R0204X | 24890 | NE | N | Allopathic & Osteopathic Physicians | Radiology | Vascular & Interventional Radiology | 2085R0202X | 24890 | NE | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085R0202X | 56250 | CO | N | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085R0202X | 04-39312 | KS | N | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085R0202X | MD18855 | HI | N | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 201141130A | 05 | KS | MEDICAID | 1770558496 | 05 | SD | MEDICAID | 200659440A | 05 | OK | MEDICAID | 2015757 | 05 | MA | MEDICAID | 87881730 | 05 | NM | MEDICAID | 191281 | 05 | AZ | MEDICAID | 82653844 | 05 | CO | MEDICAID | A35829 | 01 | MA | MEDICARE ID | OTHER | 1770558496 | 05 | MT | MEDICAID | 1770558496 | 05 | IA | MEDICAID |