Provider Demographics
NPI:1962059493
Name:DIXITKUMAR N MODI MD PA
Entity type:Organization
Organization Name:DIXITKUMAR N MODI MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DIXITKUMAR
Authorized Official - Middle Name:NAVINCHANDRA
Authorized Official - Last Name:MODI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:334-327-9530
Mailing Address - Street 1:3003 TRASONA DR
Mailing Address - Street 2:
Mailing Address - City:MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32940-7670
Mailing Address - Country:US
Mailing Address - Phone:321-613-5352
Mailing Address - Fax:321-613-5356
Practice Address - Street 1:4350 N ATLANTIC AVE
Practice Address - Street 2:
Practice Address - City:COCOA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32931-3656
Practice Address - Country:US
Practice Address - Phone:334-327-9530
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-08-20
Last Update Date:2024-02-23
Deactivation Date:2024-02-20
Deactivation Code:
Reactivation Date:2024-02-23
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
No261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary CareGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL104790300Medicaid
FLME133520OtherMEDICAL LICENSE