Provider Demographics
NPI:1154506871
Name:MODANLOU, SHOHREH (MD)
Entity Type:Individual
Prefix:
First Name:SHOHREH
Middle Name:
Last Name:MODANLOU
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:750 WASHINTON STREET
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02111-1533
Mailing Address - Country:US
Mailing Address - Phone:617-636-9303
Mailing Address - Fax:
Practice Address - Street 1:750 WASHINTON STREET
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02111-1533
Practice Address - Country:US
Practice Address - Phone:617-636-9303
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-12-31
Last Update Date:2007-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA92862207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology