Provider Demographics
NPI:1881614667
Name:VOSSOUGH MODARRESS, ARASTOO (MD)
Entity type:Individual
Prefix:
First Name:ARASTOO
Middle Name:
Last Name:VOSSOUGH MODARRESS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:ARASTOO
Other - Middle Name:
Other - Last Name:VOSSOUGH
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:100 E PENN SQ
Mailing Address - Street 2:9TH FLOOR
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19107-3323
Mailing Address - Country:US
Mailing Address - Phone:267-425-9232
Mailing Address - Fax:267-425-9299
Practice Address - Street 1:3401 CIVIC CENTER BLVD
Practice Address - Street 2:CHILDREN'S HOSPITAL OF PHILADELPHIA - RADIOLOGY
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19104-4319
Practice Address - Country:US
Practice Address - Phone:215-590-1030
Practice Address - Fax:215-590-9348
Is Sole Proprietor?:No
Enumeration Date:2006-07-21
Last Update Date:2015-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA2202652085N0700X, 2085R0202X
PAMD4309902085N0700X, 2085R0202X
NJ25MA092817002085R0202X, 2085N0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085N0700XAllopathic & Osteopathic PhysiciansRadiologyNeuroradiology
No2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA2068915Medicaid
PA111902Medicare PIN
MAI09939Medicare UPIN
MAI09939Medicare UPIN