Provider Demographics
NPI:1386931186
Name:MORTAZAVI, LARRY KHASHAYAR (MD)
Entity type:Individual
Prefix:
First Name:LARRY
Middle Name:KHASHAYAR
Last Name:MORTAZAVI
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 1:155 INVERNESS DR W
Mailing Address - Street 2:STE. 200
Mailing Address - City:ENGLEWOOD
Mailing Address - State:CO
Mailing Address - Zip Code:80112-5095
Mailing Address - Country:US
Mailing Address - Phone:720-707-6363
Mailing Address - Fax:
Practice Address - Street 1:61 W DAVIES AVE N
Practice Address - Street 2:
Practice Address - City:LITTLETON
Practice Address - State:CO
Practice Address - Zip Code:80120-5252
Practice Address - Country:US
Practice Address - Phone:720-707-6363
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-30
Last Update Date:2016-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CODR.00568072084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology