Provider Demographics
NPI:1023391315
Name:MODLO, GARRETT JON (MS,RD,CDN)
Entity type:Individual
Prefix:MR
First Name:GARRETT
Middle Name:JON
Last Name:MODLO
Suffix:
Gender:M
Credentials:MS,RD,CDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:622 LACEY DR
Mailing Address - Street 2:
Mailing Address - City:ENDWELL
Mailing Address - State:NY
Mailing Address - Zip Code:13760-2545
Mailing Address - Country:US
Mailing Address - Phone:607-321-1135
Mailing Address - Fax:
Practice Address - Street 1:622 LACEY DR
Practice Address - Street 2:
Practice Address - City:ENDWELL
Practice Address - State:NY
Practice Address - Zip Code:13760-2545
Practice Address - Country:US
Practice Address - Phone:607-321-1135
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-22
Last Update Date:2011-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY005584133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY005584Medicaid
NY925332Medicaid