Provider Demographics
NPI:1063142115
Name:MODERA CLINIC GI, PLLC
Entity type:Organization
Organization Name:MODERA CLINIC GI, PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:TREVOR
Authorized Official - Middle Name:
Authorized Official - Last Name:HUBER
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:972-987-0458
Mailing Address - Street 1:5575 FRISCO SQUARE BLVD
Mailing Address - Street 2:#220
Mailing Address - City:FRISCO
Mailing Address - State:TX
Mailing Address - Zip Code:75034-3303
Mailing Address - Country:US
Mailing Address - Phone:469-920-2302
Mailing Address - Fax:
Practice Address - Street 1:5575 FRISCO SQUARE BLVD
Practice Address - Street 2:220
Practice Address - City:FRISCO
Practice Address - State:TX
Practice Address - Zip Code:75034-3303
Practice Address - Country:US
Practice Address - Phone:469-920-2302
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-06-13
Last Update Date:2023-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Single Specialty