Provider Demographics
NPI:1841416740
Name:MODARESI, MOHAMAD MIKE (LSA)
Entity Type:Individual
Prefix:
First Name:MOHAMAD
Middle Name:MIKE
Last Name:MODARESI
Suffix:
Gender:M
Credentials:LSA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4815 JESSICA CT
Mailing Address - Street 2:
Mailing Address - City:SUGAR LAND
Mailing Address - State:TX
Mailing Address - Zip Code:77479-5444
Mailing Address - Country:US
Mailing Address - Phone:832-368-2200
Mailing Address - Fax:
Practice Address - Street 1:4815 JESSICA CT
Practice Address - Street 2:
Practice Address - City:SUGAR LAND
Practice Address - State:TX
Practice Address - Zip Code:77479-5444
Practice Address - Country:US
Practice Address - Phone:832-368-2200
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-18
Last Update Date:2012-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXSA00285246ZC0007X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZC0007XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Assistant