Provider Demographics
NPI:1659562585
Name:MODY, KETAN R (MD)
Entity Type:Individual
Prefix:DR
First Name:KETAN
Middle Name:R
Last Name:MODY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 3231
Mailing Address - Street 2:
Mailing Address - City:OAK BROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60522-3231
Mailing Address - Country:US
Mailing Address - Phone:630-789-3764
Mailing Address - Fax:630-794-9998
Practice Address - Street 1:760 PASQUINELLI DR STE 304
Practice Address - Street 2:
Practice Address - City:WESTMONT
Practice Address - State:IL
Practice Address - Zip Code:60559-1290
Practice Address - Country:US
Practice Address - Phone:630-789-3764
Practice Address - Fax:630-206-2490
Is Sole Proprietor?:No
Enumeration Date:2007-08-06
Last Update Date:2019-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036119306207QS0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILIL2367001OtherMEDICARE INDIVIDUAL PTAN
ILK44733Medicare UPIN