Provider Demographics
NPI:1649794876
Name:MODI, MITUL B (MD)
Entity type:Individual
Prefix:
First Name:MITUL
Middle Name:B
Last Name:MODI
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 1:2160 S 1ST AVE
Mailing Address - Street 2:
Mailing Address - City:MAYWOOD
Mailing Address - State:IL
Mailing Address - Zip Code:60153-3328
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2160 S 1ST AVE
Practice Address - Street 2:
Practice Address - City:MAYWOOD
Practice Address - State:IL
Practice Address - Zip Code:60153-3328
Practice Address - Country:US
Practice Address - Phone:248-839-7383
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-07-31
Last Update Date:2025-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL125079219207ZD0900X
390200000X
IL036164764207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
No207ZD0900XAllopathic & Osteopathic PhysiciansPathologyDermatopathology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program