Provider Demographics
NPI:1639257140
Name:MODY, MANOJ V (MD)
Entity Type:Individual
Prefix:
First Name:MANOJ
Middle Name:V
Last Name:MODY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:12093 W MORGAN OAK DR
Mailing Address - Street 2:
Mailing Address - City:GREENFIELD
Mailing Address - State:WI
Mailing Address - Zip Code:53228-1035
Mailing Address - Country:US
Mailing Address - Phone:414-321-8662
Mailing Address - Fax:414-306-7002
Practice Address - Street 1:12093 W MORGAN OAK DR
Practice Address - Street 2:
Practice Address - City:GREENFIELD
Practice Address - State:WI
Practice Address - Zip Code:53228-1035
Practice Address - Country:US
Practice Address - Phone:414-321-8662
Practice Address - Fax:414-306-7002
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-01
Last Update Date:2012-03-06
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
WI33750207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI02120-0098Medicare PIN