Provider Demographics
NPI:1790778876
Name:MODRAK, MARYANNE E (MD)
Entity Type:Individual
Prefix:
First Name:MARYANNE
Middle Name:E
Last Name:MODRAK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:33 LEWIS ROAD
Mailing Address - Street 2:2ND FLOOR
Mailing Address - City:BINGHAMTON
Mailing Address - State:NY
Mailing Address - Zip Code:13903-5227
Mailing Address - Country:US
Mailing Address - Phone:607-729-8156
Mailing Address - Fax:607-729-3982
Practice Address - Street 1:507 MAIN ST
Practice Address - Street 2:
Practice Address - City:JOHNSON CITY
Practice Address - State:NY
Practice Address - Zip Code:13790-1810
Practice Address - Country:US
Practice Address - Phone:607-763-8008
Practice Address - Fax:607-763-8019
Is Sole Proprietor?:No
Enumeration Date:2005-08-24
Last Update Date:2015-12-09
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
NY162487-1207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01025754Medicaid
C59290Medicare UPIN
NYBB4497Medicare PIN