Provider Demographics
NPI:1003864380
Name:MODIANO, MANUEL (MD)
Entity Type:Individual
Prefix:
First Name:MANUEL
Middle Name:
Last Name:MODIANO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3945 E PARADISE FALLS DR STE 201
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85712-6687
Mailing Address - Country:US
Mailing Address - Phone:520-689-7030
Mailing Address - Fax:520-395-9796
Practice Address - Street 1:3945 E PARADISE FALLS DR STE 105
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85712-6686
Practice Address - Country:US
Practice Address - Phone:520-689-7030
Practice Address - Fax:520-395-9796
Is Sole Proprietor?:No
Enumeration Date:2006-05-05
Last Update Date:2020-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ17060207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ86-0938204OtherTIN
AZ286973Medicaid
AZ286973Medicaid
AZZ25293Medicare PIN