Provider Demographics
NPI:1669178695
Name:MODI, DEVEN SETH
Entity type:Individual
Prefix:
First Name:DEVEN
Middle Name:SETH
Last Name:MODI
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2549 AMBLE WAY # 2321
Mailing Address - Street 2:
Mailing Address - City:LAND O LAKES
Mailing Address - State:FL
Mailing Address - Zip Code:34639-3727
Mailing Address - Country:US
Mailing Address - Phone:941-724-1053
Mailing Address - Fax:
Practice Address - Street 1:1600 SW ARCHER RD
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:FL
Practice Address - Zip Code:32610-3003
Practice Address - Country:US
Practice Address - Phone:352-273-6815
Practice Address - Fax:352-273-7515
Is Sole Proprietor?:Yes
Enumeration Date:2023-02-01
Last Update Date:2025-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9120314363A00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL127927400Medicaid