Provider Demographics
NPI:1265418941
Name:MODLIN, IRVIN M (MD PHD)
Entity type:Individual
Prefix:
First Name:IRVIN
Middle Name:M
Last Name:MODLIN
Suffix:
Gender:M
Credentials:MD PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:789 HOWARD AVE
Mailing Address - Street 2:FITKIN BUILDING - 2ND FLOOR
Mailing Address - City:NEW HAVEN
Mailing Address - State:CT
Mailing Address - Zip Code:06519-1304
Mailing Address - Country:US
Mailing Address - Phone:203-785-3207
Mailing Address - Fax:203-785-3826
Practice Address - Street 1:789 HOWARD AVE
Practice Address - Street 2:FITKIN BUILDING - 2ND FLOOR
Practice Address - City:NEW HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06519-1304
Practice Address - Country:US
Practice Address - Phone:203-785-3207
Practice Address - Fax:203-785-3826
Is Sole Proprietor?:No
Enumeration Date:2005-12-15
Last Update Date:2011-03-16
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CT025885208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT001258854Medicaid
CT001258854Medicaid
CT020000713Medicare ID - Type Unspecified