Provider Demographics
NPI:1164481891
Name:MODY, SUSHIL S (MD)
Entity Type:Individual
Prefix:
First Name:SUSHIL
Middle Name:S
Last Name:MODY
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 1:5545 BRIDLE RD
Mailing Address - Street 2:
Mailing Address - City:STROUDSBURG
Mailing Address - State:PA
Mailing Address - Zip Code:18360-9197
Mailing Address - Country:US
Mailing Address - Phone:570-793-3254
Mailing Address - Fax:866-471-3154
Practice Address - Street 1:175 E BROWN ST
Practice Address - Street 2:SUITE 108
Practice Address - City:E STROUDSBURG
Practice Address - State:PA
Practice Address - Zip Code:18301-3098
Practice Address - Country:US
Practice Address - Phone:570-476-3585
Practice Address - Fax:570-421-9014
Is Sole Proprietor?:No
Enumeration Date:2006-03-21
Last Update Date:2012-02-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD422414208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1009422450002Medicaid
PAI05198Medicare UPIN