Provider Demographics
NPI:1891829222
Name:MODI, MITESHKUMAR N (PA-C)
Entity Type:Individual
Prefix:MR
First Name:MITESHKUMAR
Middle Name:N
Last Name:MODI
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9835 GARDEN CT
Mailing Address - Street 2:
Mailing Address - City:SCHILLER PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60176-2101
Mailing Address - Country:US
Mailing Address - Phone:847-671-0521
Mailing Address - Fax:
Practice Address - Street 1:2401 W MAIN ST
Practice Address - Street 2:
Practice Address - City:MARION
Practice Address - State:IL
Practice Address - Zip Code:62959-1188
Practice Address - Country:US
Practice Address - Phone:618-997-5311
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant