Provider Demographics
NPI:1205367000
Name:MODARRESI, MILAD
Entity type:Individual
Prefix:
First Name:MILAD
Middle Name:
Last Name:MODARRESI
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1600 MEDICAL CENTER DR STE 2000
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON
Mailing Address - State:WV
Mailing Address - Zip Code:25701-3656
Mailing Address - Country:US
Mailing Address - Phone:304-691-1282
Mailing Address - Fax:
Practice Address - Street 1:500 BURLINGTON RD
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:OH
Practice Address - Zip Code:45640-9360
Practice Address - Country:US
Practice Address - Phone:740-288-4625
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-03-23
Last Update Date:2022-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
OH35.144058207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program