Provider Demographics
NPI:1851382758
Name:MODI, CHANDRA M (MD)
Entity Type:Individual
Prefix:
First Name:CHANDRA
Middle Name:M
Last Name:MODI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9136 RIDGEWAY AVE
Mailing Address - Street 2:
Mailing Address - City:SKOKIE
Mailing Address - State:IL
Mailing Address - Zip Code:60076-1754
Mailing Address - Country:US
Mailing Address - Phone:847-677-6008
Mailing Address - Fax:847-677-6007
Practice Address - Street 1:9136 RIDGEWAY AVE
Practice Address - Street 2:
Practice Address - City:SKOKIE
Practice Address - State:IL
Practice Address - Zip Code:60076-1754
Practice Address - Country:US
Practice Address - Phone:847-677-6008
Practice Address - Fax:847-677-6007
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-31
Last Update Date:2013-04-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IL036044793207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
D12767Medicare UPIN
703190Medicare ID - Type Unspecified