Provider Demographics
NPI:1790074490
Name:MODZELEWSKA, MAYA (MD)
Entity Type:Individual
Prefix:DR
First Name:MAYA
Middle Name:
Last Name:MODZELEWSKA
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 1:1100 22ND ST SE
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97302-6558
Mailing Address - Country:US
Mailing Address - Phone:503-971-6771
Mailing Address - Fax:503-385-8421
Practice Address - Street 1:1100 22ND ST SE
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97302-6558
Practice Address - Country:US
Practice Address - Phone:585-275-3274
Practice Address - Fax:585-442-2949
Is Sole Proprietor?:No
Enumeration Date:2011-04-04
Last Update Date:2023-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD181084208100000X, 2081P2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2081P2900XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationPain Medicine
No208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500719962Medicaid