Basic Information
| Provider Information | |||||||||
| NPI: | 1790930535 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BOLOURI | ||||||||
| FirstName: | MARJAN | ||||||||
| MiddleName: | SEDIGHA | ||||||||
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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: | 501 E HAMPDEN AVE | ||||||||
| Address2: | |||||||||
| City: | ENGLEWOOD | ||||||||
| State: | CO | ||||||||
| PostalCode: | 801132702 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3037619190 | ||||||||
| FaxNumber: | 7208744462 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/20/2008 | ||||||||
| LastUpdateDate: | 04/07/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 2085R0202X | 53503 | CO | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085R0202X | 27754 | NE | N | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085R0202X | 04-37113 | KS | N | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085R0202X | 17588 | HI | N | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 0000343871 | 01 | HI | HMSA ALL PRODUCTS | OTHER | 10026277800 | 05 | NE | MEDICAID | 200545800A | 05 | OK | MEDICAID | 10026277300 | 05 | NE | MEDICAID | 10026277400 | 05 | NE | MEDICAID | 1002627770 | 05 | NE | MEDICAID | 1790930535 | 05 | WY | MEDICAID | 1790930535 | 05 | UT | MEDICAID | 935836 | 05 | AZ | MEDICAID | 10025709000 | 05 | NE | MEDICAID | 10026277600 | 05 | NE | MEDICAID | 10026277500 | 05 | NE | MEDICAID | 1790930535 | 05 | IA | MEDICAID | 201098850A | 05 | KS | MEDICAID | 47184841 | 05 | CO | MEDICAID | 1790930535 | 05 | MT | MEDICAID | 92403328 | 05 | NM | MEDICAID |