Provider Demographics
NPI:1598011157
Name:MODESTO, MARGARITA (MSED)
Entity type:Individual
Prefix:
First Name:MARGARITA
Middle Name:
Last Name:MODESTO
Suffix:
Gender:F
Credentials:MSED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3647 CORLEAR AVE
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10463-2305
Mailing Address - Country:US
Mailing Address - Phone:718-548-1982
Mailing Address - Fax:
Practice Address - Street 1:3647 CORLEAR AVE
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10463-2305
Practice Address - Country:US
Practice Address - Phone:718-548-1982
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-07-31
Last Update Date:2012-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY171W0000X171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY97532OtherCPT