Provider Demographics
NPI:1346248515
Name:MODUR, PRADEEP (MD)
Entity Type:Individual
Prefix:
First Name:PRADEEP
Middle Name:
Last Name:MODUR
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 1:1600 W 38TH ST STE 200
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78731-6405
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1600 W 38TH ST STE 200
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78731-6405
Practice Address - Country:US
Practice Address - Phone:512-324-3540
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-07-12
Last Update Date:2024-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXM58412084N0600X, 2084E0001X, 2084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
No2084N0600XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyClinical Neurophysiology
No2084E0001XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyEpilepsy
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64017767Medicaid
H20037Medicare UPIN
KY64017767Medicaid