Provider Demographics
NPI:1811335433
Name:MODARRESSI, TAHER (MD)
Entity type:Individual
Prefix:
First Name:TAHER
Middle Name:
Last Name:MODARRESSI
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 1:21 ROUTE 31 N STE B6
Mailing Address - Street 2:
Mailing Address - City:PENNINGTON
Mailing Address - State:NJ
Mailing Address - Zip Code:08534-1621
Mailing Address - Country:US
Mailing Address - Phone:609-951-3944
Mailing Address - Fax:609-955-3078
Practice Address - Street 1:21 ROUTE 31 N STE B6
Practice Address - Street 2:
Practice Address - City:PENNINGTON
Practice Address - State:NJ
Practice Address - Zip Code:08534-1621
Practice Address - Country:US
Practice Address - Phone:609-951-3944
Practice Address - Fax:609-955-3078
Is Sole Proprietor?:No
Enumeration Date:2013-06-05
Last Update Date:2023-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA10293500207RB0002X, 207RE0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & Metabolism
No207RB0002XAllopathic & Osteopathic PhysiciansInternal MedicineObesity Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0649881Medicaid