Provider Demographics
NPI:1104847466
Name:MODAD, PATRICIA ISABEL (MD, FACOG)
Entity Type:Individual
Prefix:DR
First Name:PATRICIA
Middle Name:ISABEL
Last Name:MODAD
Suffix:
Gender:F
Credentials:MD, FACOG
Other - Prefix:DR
Other - First Name:PATRICIA
Other - Middle Name:ISABEL
Other - Last Name:GOMEZ-MODAD
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD, FACOG
Mailing Address - Street 1:P.O.BOX 351295
Mailing Address - Street 2:
Mailing Address - City:PALM COAST
Mailing Address - State:FL
Mailing Address - Zip Code:32137-1295
Mailing Address - Country:US
Mailing Address - Phone:386-447-6831
Mailing Address - Fax:386-447-6834
Practice Address - Street 1:50 LEANNI WAY
Practice Address - Street 2:SUITES A3 & A4
Practice Address - City:PALM COAST
Practice Address - State:FL
Practice Address - Zip Code:32137-4751
Practice Address - Country:US
Practice Address - Phone:386-447-6831
Practice Address - Fax:386-447-6834
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-22
Last Update Date:2011-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01053870A207V00000X
FLME103310207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL001042100Medicaid
FL001042100Medicaid
H85965Medicare UPIN