Provider Demographics
NPI:1851307045
Name:MODLIN, LYLE TERRENCE (DPM)
Entity Type:Individual
Prefix:
First Name:LYLE
Middle Name:TERRENCE
Last Name:MODLIN
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:43 OLD SOLOMONS ISLAND RD
Mailing Address - Street 2:SUITE 102
Mailing Address - City:ANNAPOLIS
Mailing Address - State:MD
Mailing Address - Zip Code:21401-3850
Mailing Address - Country:US
Mailing Address - Phone:410-263-3100
Mailing Address - Fax:410-263-7380
Practice Address - Street 1:43 OLD SOLOMONS ISLAND RD
Practice Address - Street 2:SUITE 102
Practice Address - City:ANNAPOLIS
Practice Address - State:MD
Practice Address - Zip Code:21401-3850
Practice Address - Country:US
Practice Address - Phone:410-263-3100
Practice Address - Fax:410-263-7380
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-31
Last Update Date:2014-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD00631213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD463068800Medicaid
MD4081901Medicaid
MD0908620001Medicare NSC
MD4081901Medicaid
MD463068800Medicaid
MDT30829Medicare UPIN