Healthcare Provider Details

I. General information

NPI: 1790858520
Provider Name (Legal Business Name): KIAN ALI MODANLOU M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/17/2006
Last Update Date: 05/12/2025
Certification Date: 05/12/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

701 E HAMPDEN AVE STE 420
ENGLEWOOD CO
80113-2760
US

IV. Provider business mailing address

8490 E CRESCENT PKWY STE 380
GREENWOOD VILLAGE CO
80111-2815
US

V. Phone/Fax

Practice location:
  • Phone: 303-789-1877
  • Fax: 303-789-2628
Mailing address:
  • Phone: 303-957-1310
  • Fax: 303-761-4252

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code204F00000X
TaxonomyTransplant Surgery Physician
License Number2006020979
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number2006020979
License Number StateMO
# 3
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberDR.0041865
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: