Provider Demographics
NPI:1821312331
Name:MODICA, EDWARD J (ATC,EMT-B)
Entity Type:Individual
Prefix:MR
First Name:EDWARD
Middle Name:J
Last Name:MODICA
Suffix:
Gender:M
Credentials:ATC,EMT-B
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:434 N BLEECKER DR
Mailing Address - Street 2:
Mailing Address - City:MASSAPEQUA
Mailing Address - State:NY
Mailing Address - Zip Code:11758-1340
Mailing Address - Country:US
Mailing Address - Phone:516-721-6541
Mailing Address - Fax:
Practice Address - Street 1:434 N BLEECKER DR
Practice Address - Street 2:
Practice Address - City:MASSAPEQUA
Practice Address - State:NY
Practice Address - Zip Code:11758-1340
Practice Address - Country:US
Practice Address - Phone:516-721-6541
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-03-26
Last Update Date:2010-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY000370-1174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY000370-1OtherNY STATE LICENSE