Provider Demographics
NPI:1124238506
Name:MODI, DIXITKUMAR N (MD)
Entity type:Individual
Prefix:DR
First Name:DIXITKUMAR
Middle Name:N
Last Name:MODI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4350 N ATLANTIC AVE STE 1
Mailing Address - Street 2:
Mailing Address - City:COCOA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32931-3656
Mailing Address - Country:US
Mailing Address - Phone:321-613-5352
Mailing Address - Fax:321-613-5356
Practice Address - Street 1:4350 N ATLANTIC AVE
Practice Address - Street 2:
Practice Address - City:COCOA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32931-3656
Practice Address - Country:US
Practice Address - Phone:334-327-9530
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-23
Last Update Date:2021-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME133520207Q00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL023052500Medicaid
FLME133520OtherMEDICAL LICENSE