Provider Demographics
NPI:1558714139
Name:MODLIN, DAVID (MD)
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:
Last Name:MODLIN
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 1:300 EAST HOSPITAL ROAD
Mailing Address - Street 2:
Mailing Address - City:FORT GORDON
Mailing Address - State:GA
Mailing Address - Zip Code:30905-5650
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:300 EAST HOSPITAL ROAD
Practice Address - Street 2:GENERAL SURGERY, DDEAMC
Practice Address - City:FORT GORDON
Practice Address - State:GA
Practice Address - Zip Code:30905-5650
Practice Address - Country:US
Practice Address - Phone:706-787-2567
Practice Address - Fax:706-787-2347
Is Sole Proprietor?:No
Enumeration Date:2016-07-19
Last Update Date:2018-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA079834390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program