Provider Demographics
NPI:1942590401
Name:PATRICIA MODAD, MD, PA
Entity Type:Organization
Organization Name:PATRICIA MODAD, MD, PA
Other - Org Name:PALM COAST OB GYN
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:PATRICIA
Authorized Official - Middle Name:ISABEL
Authorized Official - Last Name:MODAD
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:386-447-6831
Mailing Address - Street 1:50 LEANNI WAY
Mailing Address - Street 2:SUITES A3 & A4
Mailing Address - City:PALM COAST
Mailing Address - State:FL
Mailing Address - Zip Code:32137-4751
Mailing Address - Country:US
Mailing Address - Phone:386-447-6831
Mailing Address - Fax:386-447-6834
Practice Address - Street 1:50 LEANNI WAY
Practice Address - Street 2:SUITES A3 & A4
Practice Address - City:PALM COAST
Practice Address - State:FL
Practice Address - Zip Code:32137-4751
Practice Address - Country:US
Practice Address - Phone:386-447-6831
Practice Address - Fax:386-447-6834
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-04-18
Last Update Date:2011-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME 103310207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLEY172AMedicare PIN