Provider Demographics
NPI:1063413995
Name:MODISETTE, JAMES KEVIN (MD)
Entity type:Individual
Prefix:MR
First Name:JAMES
Middle Name:KEVIN
Last Name:MODISETTE
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 1:604 N. ACADIA RD.
Mailing Address - Street 2:SUITE 405
Mailing Address - City:THIBODAUX
Mailing Address - State:LA
Mailing Address - Zip Code:70301
Mailing Address - Country:US
Mailing Address - Phone:985-446-0871
Mailing Address - Fax:985-446-0874
Practice Address - Street 1:604 N. ACADIA RD.
Practice Address - Street 2:SUITE 405
Practice Address - City:THIBODAUX
Practice Address - State:LA
Practice Address - Zip Code:70301
Practice Address - Country:US
Practice Address - Phone:985-446-0871
Practice Address - Fax:985-446-0874
Is Sole Proprietor?:No
Enumeration Date:2005-08-02
Last Update Date:2009-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA22699207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1492141Medicaid
7814220OtherAETNA
LA1492141Medicaid
G57889Medicare UPIN
4A019CE76Medicare ID - Type Unspecified