Provider Demographics
NPI:1184917999
Name:MODIRI, ALEXANDRA NICOLE (MD)
Entity type:Individual
Prefix:DR
First Name:ALEXANDRA
Middle Name:NICOLE
Last Name:MODIRI
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 1:1521 SHIPSVIEW RD
Mailing Address - Street 2:
Mailing Address - City:ANNAPOLIS
Mailing Address - State:MD
Mailing Address - Zip Code:21409-5726
Mailing Address - Country:US
Mailing Address - Phone:301-233-2070
Mailing Address - Fax:
Practice Address - Street 1:9200 W WISCONSIN AVE
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53226-3522
Practice Address - Country:US
Practice Address - Phone:414-805-3666
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-05-26
Last Update Date:2016-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMT199800207R00000X
WI62009-20207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine