Provider Demographics
NPI:1851739304
Name:MODH, BRINDA G
Entity Type:Individual
Prefix:
First Name:BRINDA
Middle Name:G
Last Name:MODH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 361095
Mailing Address - Street 2:
Mailing Address - City:MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32936-1095
Mailing Address - Country:US
Mailing Address - Phone:321-255-4003
Mailing Address - Fax:321-255-2728
Practice Address - Street 1:8041 SPYGLASS HILL RD STE 102
Practice Address - Street 2:
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32940-8559
Practice Address - Country:US
Practice Address - Phone:321-255-4003
Practice Address - Fax:321-255-2728
Is Sole Proprietor?:No
Enumeration Date:2013-06-06
Last Update Date:2020-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYME116384207R00000X
FLME116384207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLHN805ZMedicare PIN