Provider Demographics
NPI:1215017801
Name:MODY, SMITA S (MD)
Entity Type:Individual
Prefix:
First Name:SMITA
Middle Name:S
Last Name:MODY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:360 W RUDDLE ST
Mailing Address - Street 2:
Mailing Address - City:COALDALE
Mailing Address - State:PA
Mailing Address - Zip Code:18218-1027
Mailing Address - Country:US
Mailing Address - Phone:570-645-8256
Mailing Address - Fax:570-645-8875
Practice Address - Street 1:360 W RUDDLE ST
Practice Address - Street 2:
Practice Address - City:COALDALE
Practice Address - State:PA
Practice Address - Zip Code:18218-1027
Practice Address - Country:US
Practice Address - Phone:570-645-8256
Practice Address - Fax:570-645-8875
Is Sole Proprietor?:No
Enumeration Date:2006-10-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD034814L207LP2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA159487Medicare ID - Type Unspecified