Healthcare Provider Details

I. General information

NPI: 1447609466
Provider Name (Legal Business Name): ALAN JACOB HISE M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/09/2016
Last Update Date: 04/19/2022
Certification Date: 04/19/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11600 W 2ND PL
LAKEWOOD CO
80228-1527
US

IV. Provider business mailing address

1819 DENVER WEST DR SUITE 101
LAKEWOOD CO
80401-3172
US

V. Phone/Fax

Practice location:
  • Phone: 303-854-9888
  • Fax:
Mailing address:
  • Phone: 303-854-9888
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0204X
TaxonomyVascular & Interventional Radiology Physician
License NumberDR.0067655
License Number StateCO
# 2
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberDR.0067655
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: