Provider Demographics
NPI:1013560846
Name:MODRAK, MAXWELL JOSEPH (MD)
Entity Type:Individual
Prefix:
First Name:MAXWELL
Middle Name:JOSEPH
Last Name:MODRAK
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 1:155 EDGEMONT RD
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14620-4521
Mailing Address - Country:US
Mailing Address - Phone:585-613-1148
Mailing Address - Fax:
Practice Address - Street 1:601 ELMWOOD AVE
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14642-0001
Practice Address - Country:US
Practice Address - Phone:585-275-2100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-21
Last Update Date:2020-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program