Provider Demographics
NPI:1558637538
Name:NAVETTA-MODROV, BRIANNE (MD)
Entity type:Individual
Prefix:
First Name:BRIANNE
Middle Name:
Last Name:NAVETTA-MODROV
Suffix:
Gender:F
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:PO BOX 1559
Mailing Address - Street 2:
Mailing Address - City:STONY BROOK
Mailing Address - State:NY
Mailing Address - Zip Code:11790-0989
Mailing Address - Country:US
Mailing Address - Phone:631-444-0650
Mailing Address - Fax:
Practice Address - Street 1:500 COMMACK RD STE 103
Practice Address - Street 2:
Practice Address - City:COMMACK
Practice Address - State:NY
Practice Address - Zip Code:11725-5020
Practice Address - Country:US
Practice Address - Phone:631-444-0580
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-03-24
Last Update Date:2018-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY272491207K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207K00000XAllopathic & Osteopathic PhysiciansAllergy & Immunology