Provider Demographics
NPI:1083640825
Name:BOZORGZADEH, ADEL (MD)
Entity type:Individual
Prefix:DR
First Name:ADEL
Middle Name:
Last Name:BOZORGZADEH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:201 W LAKEWAY RD STE 1004
Mailing Address - Street 2:
Mailing Address - City:GILLETTE
Mailing Address - State:WY
Mailing Address - Zip Code:82718-6349
Mailing Address - Country:US
Mailing Address - Phone:307-387-9850
Mailing Address - Fax:307-387-9890
Practice Address - Street 1:469 HIGHWAY 50
Practice Address - Street 2:
Practice Address - City:GILLETTE
Practice Address - State:WY
Practice Address - Zip Code:82718-9330
Practice Address - Country:US
Practice Address - Phone:307-387-9850
Practice Address - Fax:307-387-9890
Is Sole Proprietor?:No
Enumeration Date:2006-06-23
Last Update Date:2025-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA238379204F00000X
WYTL8537208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No204F00000XAllopathic & Osteopathic PhysiciansTransplant Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA110081143AMedicaid
MA110081143AMedicaid
H00566Medicare UPIN