Provider Demographics
NPI:1295749851
Name:MODICA, ANTHONY L (MD)
Entity type:Individual
Prefix:
First Name:ANTHONY
Middle Name:L
Last Name:MODICA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1514 JEFFERSON HWY
Mailing Address - Street 2:
Mailing Address - City:NEW ORLEANS
Mailing Address - State:LA
Mailing Address - Zip Code:70121-2429
Mailing Address - Country:US
Mailing Address - Phone:504-842-4000
Mailing Address - Fax:540-891-5769
Practice Address - Street 1:1514 JEFFERSON HWY
Practice Address - Street 2:
Practice Address - City:NEW ORLEANS
Practice Address - State:LA
Practice Address - Zip Code:70121-2429
Practice Address - Country:US
Practice Address - Phone:504-842-3470
Practice Address - Fax:540-891-5769
Is Sole Proprietor?:No
Enumeration Date:2006-07-28
Last Update Date:2024-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAMD.08792R2085P0229X, 2085R0202X
MDD00503582085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No2085P0229XAllopathic & Osteopathic PhysiciansRadiologyPediatric Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS07828361Medicaid
MD205744100Medicaid
LA2347241Medicaid
MD60234801OtherBLUE SHIELD
DC80430028OtherBLUE SHIELD
MD60234801OtherBLUE SHIELD
G26071Medicare UPIN
DC863057D05Medicare PIN
LA2347241Medicaid
LA324179YH3UMedicare PIN