Provider Demographics
NPI:1790724557
Name:MODI, ANANG (DO)
Entity Type:Individual
Prefix:
First Name:ANANG
Middle Name:
Last Name:MODI
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:55 WATER ST
Mailing Address - Street 2:12TH FLOOR - CREDENTIALING
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10041-0004
Mailing Address - Country:US
Mailing Address - Phone:646-680-2888
Mailing Address - Fax:516-542-5556
Practice Address - Street 1:640 HAWKINS AVE
Practice Address - Street 2:
Practice Address - City:LAKE RONKONKOMA
Practice Address - State:NY
Practice Address - Zip Code:11779-2324
Practice Address - Country:US
Practice Address - Phone:631-737-0100
Practice Address - Fax:631-417-1117
Is Sole Proprietor?:No
Enumeration Date:2006-06-06
Last Update Date:2021-03-03
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NY231966207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02800686Medicaid
NY02800686Medicaid