Provider Demographics
NPI:1538564018
Name:MODOMA PHYSICAL MEDICINE
Entity type:Organization
Organization Name:MODOMA PHYSICAL MEDICINE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:
Authorized Official - Last Name:DEMARQUE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:817-308-8477
Mailing Address - Street 1:4020 N MACARTHUR BLVD
Mailing Address - Street 2:#122-286
Mailing Address - City:IRVING
Mailing Address - State:TX
Mailing Address - Zip Code:75038-6419
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5301 VILLAGE CREEK DR
Practice Address - Street 2:SUITE B
Practice Address - City:PLANO
Practice Address - State:TX
Practice Address - Zip Code:75093-4838
Practice Address - Country:US
Practice Address - Phone:972-250-3443
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-10-27
Last Update Date:2014-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center