Provider Demographics
NPI:1720011943
Name:MODWEL, KUMKUM (MD)
Entity Type:Individual
Prefix:
First Name:KUMKUM
Middle Name:
Last Name:MODWEL
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 1:895 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:TORRINGTON
Mailing Address - State:CT
Mailing Address - Zip Code:06790-3918
Mailing Address - Country:US
Mailing Address - Phone:860-489-1291
Mailing Address - Fax:860-489-1804
Practice Address - Street 1:895 E MAIN ST
Practice Address - Street 2:
Practice Address - City:TORRINGTON
Practice Address - State:CT
Practice Address - Zip Code:06790-3918
Practice Address - Country:US
Practice Address - Phone:860-489-1291
Practice Address - Fax:860-489-1804
Is Sole Proprietor?:No
Enumeration Date:2006-07-09
Last Update Date:2013-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT039256207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT001392563Medicaid
D400070046Medicare Oscar/Certification
CT001392563Medicaid