Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 204F00000X | Transplant Surgeon | 2006020979 | MO |
N | 208200000X | Surgeon | 2006020979 | MO |
N | 208600000X | Surgeon | 2006020979 | MO |
Y | 208200000X | Surgeon | DR.0041865 | CO |
Y | 208600000X | Surgeon | DR.0041865 | CO |
NPI | 1790858520 |
---|---|
Provider Name | Kian Ali Modanlou |
First Address | Englewood, CO 80110-2426 |
Second Address | Englewood, CO 80113-2760 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 17/11/2006 |
Last Update Date | 22/10/2021 |