Provider Demographics
NPI:1417110461
Name:MODY, TEJAL (MD)
Entity Type:Individual
Prefix:DR
First Name:TEJAL
Middle Name:
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:PO BOX 191
Mailing Address - Street 2:PROVIDER ENROLLMENT DEPARTMENT
Mailing Address - City:ROCKLAND
Mailing Address - State:DE
Mailing Address - Zip Code:19732-0191
Mailing Address - Country:US
Mailing Address - Phone:302-651-6212
Mailing Address - Fax:302-651-4945
Practice Address - Street 1:101 APPLIED BANK BLVD STE 11
Practice Address - Street 2:NEMOURS DUPONT PEDIATRICS, GLEN MILLS
Practice Address - City:GLEN MILLS
Practice Address - State:PA
Practice Address - Zip Code:19342-3501
Practice Address - Country:US
Practice Address - Phone:484-800-8630
Practice Address - Fax:484-800-8635
Is Sole Proprietor?:No
Enumeration Date:2008-07-09
Last Update Date:2017-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXP71632085R0202X
FLME1187482085R0202X, 2085P0229X
PAMD4594112085P0229X
NJ25MA100233002085P0229X
DEC100117872085P0229X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085P0229XAllopathic & Osteopathic PhysiciansRadiologyPediatric Radiology
No2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLHX185YMedicare PIN
FLHX185ZMedicare PIN
FLHX185XMedicare PIN