Provider Demographics
NPI:1528412368
Name:MODABER, MORTEZA (MD)
Entity Type:Individual
Prefix:DR
First Name:MORTEZA
Middle Name:
Last Name:MODABER
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 1:5959 S SHERWOOD FOREST BLVD
Mailing Address - Street 2:
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70816-6038
Mailing Address - Country:US
Mailing Address - Phone:225-526-0011
Mailing Address - Fax:225-765-9196
Practice Address - Street 1:4811 AMBASSADOR CAFFERY PKWY STE 401B
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:LA
Practice Address - Zip Code:70508-7265
Practice Address - Country:US
Practice Address - Phone:337-470-4978
Practice Address - Fax:337-470-4238
Is Sole Proprietor?:No
Enumeration Date:2016-04-18
Last Update Date:2021-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA3283562084V0102X, 2084N0400X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
No2084V0102XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyVascular Neurology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program