Provider Demographics
NPI:1912933516
Name:MODJESKI, NICHOLAS JOHN (MD)
Entity Type:Individual
Prefix:MR
First Name:NICHOLAS
Middle Name:JOHN
Last Name:MODJESKI
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 1:855 MANKATO AVE
Mailing Address - Street 2:
Mailing Address - City:WINONA
Mailing Address - State:MN
Mailing Address - Zip Code:55987-4868
Mailing Address - Country:US
Mailing Address - Phone:507-454-3680
Mailing Address - Fax:
Practice Address - Street 1:855 MANKATO AVE
Practice Address - Street 2:
Practice Address - City:WINONA
Practice Address - State:MN
Practice Address - Zip Code:55987-4868
Practice Address - Country:US
Practice Address - Phone:507-454-3680
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-24
Last Update Date:2012-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN50915207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine