Provider Demographics
NPI:1699773242
Name:MODY, VAISHALI (MD)
Entity type:Individual
Prefix:DR
First Name:VAISHALI
Middle Name:
Last Name:MODY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:31700 VAN DYKE AVE
Mailing Address - Street 2:
Mailing Address - City:WARREN
Mailing Address - State:MI
Mailing Address - Zip Code:48093-7949
Mailing Address - Country:US
Mailing Address - Phone:586-276-8200
Mailing Address - Fax:586-276-8181
Practice Address - Street 1:31700 VAN DYKE AVE
Practice Address - Street 2:
Practice Address - City:WARREN
Practice Address - State:MI
Practice Address - Zip Code:48093-7949
Practice Address - Country:US
Practice Address - Phone:586-276-8200
Practice Address - Fax:586-276-8181
Is Sole Proprietor?:No
Enumeration Date:2005-07-08
Last Update Date:2024-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301075960207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MII23587Medicare UPIN
MION23650003Medicare ID - Type Unspecified