Provider Demographics
NPI:1386711711
Name:FERRER, MODESON-SAMUEL BANEZ (MD)
Entity type:Individual
Prefix:DR
First Name:MODESON-SAMUEL
Middle Name:BANEZ
Last Name:FERRER
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 1:14275 MIDWAY RD
Mailing Address - Street 2:SUITE 400
Mailing Address - City:ADDISON
Mailing Address - State:TX
Mailing Address - Zip Code:75001-3614
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:610-271-4245
Practice Address - Street 1:2560 N SHADELAND AVE
Practice Address - Street 2:STE A
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46219-1705
Practice Address - Country:US
Practice Address - Phone:866-463-7284
Practice Address - Fax:610-271-4245
Is Sole Proprietor?:No
Enumeration Date:2006-11-29
Last Update Date:2018-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI207ZP0102X207ZP0102X
IN01070026A207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201046610Medicaid
IN201046610Medicaid