Provider Demographics
NPI:1114407350
Name:MODUR, SHOBANA RAGHURAM
Entity Type:Individual
Prefix:
First Name:SHOBANA
Middle Name:RAGHURAM
Last Name:MODUR
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1493 CAMBRIDGE ST
Mailing Address - Street 2:
Mailing Address - City:CAMBRIDGE
Mailing Address - State:MA
Mailing Address - Zip Code:02139-1099
Mailing Address - Country:US
Mailing Address - Phone:617-665-1185
Mailing Address - Fax:
Practice Address - Street 1:1493 CAMBRIDGE ST.
Practice Address - Street 2:CAMBRIDGE HOSPITAL
Practice Address - City:CAMBRIDGE
Practice Address - State:MA
Practice Address - Zip Code:02139
Practice Address - Country:US
Practice Address - Phone:617-665-1185
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-17
Last Update Date:2018-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker