Provider Demographics
NPI:1336148022
Name:MODIC, MARK L (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:L
Last Name:MODIC
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
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Mailing Address - Street 1:7255 OLD OAK BLVD
Mailing Address - Street 2:SUITE C412
Mailing Address - City:MIDDLEBURG HEIGHTS
Mailing Address - State:OH
Mailing Address - Zip Code:44130-3329
Mailing Address - Country:US
Mailing Address - Phone:440-816-4546
Mailing Address - Fax:440-816-4549
Practice Address - Street 1:7255 OLD OAK BLVD
Practice Address - Street 2:SUITE C412
Practice Address - City:MIDDLEBURG HEIGHTS
Practice Address - State:OH
Practice Address - Zip Code:44130-3329
Practice Address - Country:US
Practice Address - Phone:440-816-4546
Practice Address - Fax:440-816-4549
Is Sole Proprietor?:No
Enumeration Date:2005-07-15
Last Update Date:2012-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH049287207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0660931Medicaid
OH0660931Medicaid
0634941Medicare ID - Type Unspecified