Provider Demographics
NPI:1790775153
Name:MODI, MAYANK R (MD)
Entity Type:Individual
Prefix:
First Name:MAYANK
Middle Name:R
Last Name:MODI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2605 KEISER BLVD
Mailing Address - Street 2:
Mailing Address - City:WYOMISSING
Mailing Address - State:PA
Mailing Address - Zip Code:19610
Mailing Address - Country:US
Mailing Address - Phone:610-685-8500
Mailing Address - Fax:610-378-5131
Practice Address - Street 1:2605 KEISER BLVD
Practice Address - Street 2:
Practice Address - City:WYOMISSING
Practice Address - State:PA
Practice Address - Zip Code:19610
Practice Address - Country:US
Practice Address - Phone:610-685-8500
Practice Address - Fax:610-378-5131
Is Sole Proprietor?:No
Enumeration Date:2005-10-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD059078L207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0017526450004Medicaid
PA0017526450004Medicaid
027754FJEMedicare ID - Type Unspecified