Provider Demographics
NPI:1154622447
Name:KIRAN R. MODI, M.D., P.A.
Entity type:Organization
Organization Name:KIRAN R. MODI, M.D., P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:KIRAN
Authorized Official - Middle Name:R
Authorized Official - Last Name:MODI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:321-264-9100
Mailing Address - Street 1:500 N WASHINGTON AVE
Mailing Address - Street 2:SUITE # 106
Mailing Address - City:TITUSVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32796-2759
Mailing Address - Country:US
Mailing Address - Phone:321-264-9100
Mailing Address - Fax:321-264-1164
Practice Address - Street 1:500 N WASHINGTON AVE
Practice Address - Street 2:SUITE # 106
Practice Address - City:TITUSVILLE
Practice Address - State:FL
Practice Address - Zip Code:32796-2759
Practice Address - Country:US
Practice Address - Phone:321-264-9100
Practice Address - Fax:321-264-1164
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-11-03
Last Update Date:2010-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Single Specialty