Provider Demographics
NPI:1255904207
Name:MODMD A PROFESSIONAL CORPORATION
Entity type:Organization
Organization Name:MODMD A PROFESSIONAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO/MD
Authorized Official - Prefix:MRS
Authorized Official - First Name:SHARON
Authorized Official - Middle Name:NAOMI
Authorized Official - Last Name:DABBY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:833-663-6352
Mailing Address - Street 1:208 LINCOLN BLVD
Mailing Address - Street 2:
Mailing Address - City:VENICE
Mailing Address - State:CA
Mailing Address - Zip Code:90291
Mailing Address - Country:US
Mailing Address - Phone:833-663-6352
Mailing Address - Fax:424-465-3398
Practice Address - Street 1:208 LINCOLN BLVD
Practice Address - Street 2:
Practice Address - City:VENICE
Practice Address - State:CA
Practice Address - Zip Code:90291
Practice Address - Country:US
Practice Address - Phone:833-663-6352
Practice Address - Fax:424-465-3398
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-07-19
Last Update Date:2023-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes291U00000XLaboratoriesClinical Medical Laboratory
No207P00000XAllopathic & Osteopathic PhysiciansEmergency MedicineGroup - Multi-Specialty