Provider Demographics
NPI:1427504224
Name:MODAFARI, BRANDON (PT)
Entity type:Individual
Prefix:
First Name:BRANDON
Middle Name:
Last Name:MODAFARI
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 633448
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45263-3448
Mailing Address - Country:US
Mailing Address - Phone:513-569-6117
Mailing Address - Fax:513-853-4740
Practice Address - Street 1:6909 GOOD SAMARITAN DR
Practice Address - Street 2:STE. A
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45247-5208
Practice Address - Country:US
Practice Address - Phone:513-245-2500
Practice Address - Fax:513-245-5424
Is Sole Proprietor?:No
Enumeration Date:2016-08-31
Last Update Date:2016-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPT016566225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist