Provider Demographics
NPI:1184614349
Name:MODI, PRATIBHA (MD)
Entity type:Individual
Prefix:DR
First Name:PRATIBHA
Middle Name:
Last Name:MODI
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16800 W 12 MILE RD
Mailing Address - Street 2:STE 205
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48076-2108
Mailing Address - Country:US
Mailing Address - Phone:248-559-0900
Mailing Address - Fax:248-559-0011
Practice Address - Street 1:16800 W 12 MILE RD
Practice Address - Street 2:STE 205
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48076-2108
Practice Address - Country:US
Practice Address - Phone:248-559-0900
Practice Address - Fax:248-559-0011
Is Sole Proprietor?:No
Enumeration Date:2005-10-27
Last Update Date:2020-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301043398207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
0632487Medicare ID - Type Unspecified
B44203Medicare UPIN