Provider Demographics
NPI:1962957639
Name:MODERA CLINIC PLLC
Entity type:Organization
Organization Name:MODERA CLINIC PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:TREVOR
Authorized Official - Middle Name:KYLE
Authorized Official - Last Name:HUBER
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:972-987-0458
Mailing Address - Street 1:2700 E ELDORADO PKWY STE 104B
Mailing Address - Street 2:
Mailing Address - City:LITTLE ELM
Mailing Address - State:TX
Mailing Address - Zip Code:75068-5999
Mailing Address - Country:US
Mailing Address - Phone:972-987-0458
Mailing Address - Fax:877-459-3573
Practice Address - Street 1:2700 E ELDORADO PKWY STE 104B
Practice Address - Street 2:
Practice Address - City:LITTLE ELM
Practice Address - State:TX
Practice Address - Zip Code:75068-5999
Practice Address - Country:US
Practice Address - Phone:972-987-0458
Practice Address - Fax:877-459-3573
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-08-23
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXQ7559207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
1649682857OtherNPI
1174938831OtherNPI
B0226719OtherDPS
TXQ7559OtherLICENSE
TXQ9244OtherLICENSE
TXQ9244OtherLICENSE