Provider Demographics
NPI:1508868704
Name:MODI, ANIL R (MD)
Entity Type:Individual
Prefix:
First Name:ANIL
Middle Name:R
Last Name:MODI
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:300 MEDICAL DR
Mailing Address - Street 2:SUITE 701
Mailing Address - City:LAGRANGE
Mailing Address - State:GA
Mailing Address - Zip Code:30240-4130
Mailing Address - Country:US
Mailing Address - Phone:706-882-8971
Mailing Address - Fax:706-882-8971
Practice Address - Street 1:300 MEDICAL DR
Practice Address - Street 2:SUITE 701
Practice Address - City:LAGRANGE
Practice Address - State:GA
Practice Address - Zip Code:30240-4130
Practice Address - Country:US
Practice Address - Phone:706-882-8971
Practice Address - Fax:706-882-8991
Is Sole Proprietor?:No
Enumeration Date:2005-06-01
Last Update Date:2008-03-04
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Provider Licenses
StateLicense IDTaxonomies
GA048066207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00843873GMedicaid
GA511I110085Medicare Oscar/Certification
GAH07176Medicare UPIN