Keivan Ettefagh, MD

Primary specialty

Pediatrics PhysicianTaxonomy code 208000000X

License

2018-00348 Issued in NC

Practice address

2707 Henry St
Greensboro, NC 27405

Phone

(336) 574-4280

Fax

(336) 574-4634

NPI assigned

Jun 28, 2005

Sex

Male

Sole proprietor

No

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 2

Addresses

Other identifiers 1

Medicare fee-for-service enrollment

Not listed in the public Medicare enrollment file

Medicare enrollment (NPD)

Enrolled

Credentials

Doctor of Medicine

State licenses

Practice roles

Interoperability endpoints

• Direct secure messaging: keivanettefagh@cptpa.allscriptsdirect.net

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships and National Provider Directory roles.

• Carolina Pediatrics of the Triad, P.a.

  • Primary Care Clinic/Center
  • Greensboro, NC
  • NPI 1912987090
  NPD (past)

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1119916800000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1526428800000",
    "number": "1144227729",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "2707 HENRY ST",
            "city": "GREENSBORO",
            "state": "NC",
            "postal_code": "274053669",
            "telephone_number": "336-574-4280",
            "fax_number": "336-574-4634"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "2707 HENRY ST",
            "city": "GREENSBORO",
            "state": "NC",
            "postal_code": "27405",
            "telephone_number": "336-574-4280",
            "fax_number": "336-574-4634"
        }
    ],
    "practiceLocations": [
        {
            "address_1": "17 Virginia Ave",
            "address_2": "Suite 107",
            "address_purpose": "LOCATION",
            "city": "Providence",
            "state": "RI",
            "postal_code": "029054406",
            "country_code": "US",
            "telephone_number": "401-443-4990",
            "fax_number": "401-784-4902",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "basic": {
        "last_name": "ETTEFAGH",
        "first_name": "KEIVAN",
        "name_prefix": "Dr.",
        "credential": "MD",
        "sole_proprietor": "NO",
        "sex": "M",
        "enumeration_date": "2005-06-28",
        "last_updated": "2018-05-16",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "208000000X",
            "taxonomy_group": "",
            "desc": "Pediatrics",
            "state": "RI",
            "license": "MD07109",
            "primary": false
        },
        {
            "code": "208000000X",
            "taxonomy_group": "",
            "desc": "Pediatrics",
            "state": "NC",
            "license": "2018-00348",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "9002176",
            "state": "RI"
        }
    ],
    "endpoints": [],
    "other_names": []
}

• Cristiane Bonanato Estrela
• Erica Estrella, LCSW
• Ethereal Care, LLC
• Ethereal Home Medical LLC
• Kate Scott Ettefagh, MD
• Jessica Karam Eubanks, AGNP
• Sonja R Eubanks, MS
• Susan H Eubanks, M.ED.
• Eva Lewis Washington Et Al PTR
• Jacqueline Evans El

• Pediatrics Physician in Greensboro, NC
• Providers in Greensboro, NC by specialty
• Pediatrics Physician in North Carolina

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on May 16, 2018; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.