Provider Demographics
NPI:1982699880
Name:MODICA, LOUIS A (MD)
Entity Type:Individual
Prefix:
First Name:LOUIS
Middle Name:A
Last Name:MODICA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 699
Mailing Address - Street 2:
Mailing Address - City:MOUNTAIN HOME
Mailing Address - State:TN
Mailing Address - Zip Code:37684-0699
Mailing Address - Country:US
Mailing Address - Phone:423-433-6039
Mailing Address - Fax:423-433-6060
Practice Address - Street 1:BUILDING #8 DOGWOOD AVE
Practice Address - Street 2:VAMC
Practice Address - City:MOUNTAIN HOME
Practice Address - State:TN
Practice Address - Zip Code:37684-6062
Practice Address - Country:US
Practice Address - Phone:423-439-7201
Practice Address - Fax:423-439-7219
Is Sole Proprietor?:No
Enumeration Date:2005-09-16
Last Update Date:2011-02-03
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
TNMD15612208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
A97257Medicare UPIN