Provider Demographics
NPI:1700295680
Name:MODY, MADHU
Entity type:Individual
Prefix:DR
First Name:MADHU
Middle Name:
Last Name:MODY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17929 LAKE VISTA DR
Mailing Address - Street 2:
Mailing Address - City:ENCINO
Mailing Address - State:CA
Mailing Address - Zip Code:91316-4443
Mailing Address - Country:US
Mailing Address - Phone:818-708-3620
Mailing Address - Fax:
Practice Address - Street 1:17929 LAKE VISTA DR
Practice Address - Street 2:
Practice Address - City:ENCINO
Practice Address - State:CA
Practice Address - Zip Code:91316-4443
Practice Address - Country:US
Practice Address - Phone:818-708-3620
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-08-05
Last Update Date:2014-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA30547207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease