Provider Demographics
NPI:1679611842
Name:MODHA, POONAM (MD)
Entity Type:Individual
Prefix:
First Name:POONAM
Middle Name:
Last Name:MODHA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:345 BLACKSTONE BLVD
Mailing Address - Street 2:
Mailing Address - City:PROVIDENCE
Mailing Address - State:RI
Mailing Address - Zip Code:02906-4800
Mailing Address - Country:US
Mailing Address - Phone:401-455-6571
Mailing Address - Fax:401-455-6293
Practice Address - Street 1:345 BLACKSTONE BLVD
Practice Address - Street 2:
Practice Address - City:PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02906-4800
Practice Address - Country:US
Practice Address - Phone:401-455-6571
Practice Address - Fax:401-455-6293
Is Sole Proprietor?:No
Enumeration Date:2007-02-01
Last Update Date:2009-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIMD128392084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
RIPM75975Medicaid
RIPM75975Medicaid