1992705859 NPI number — DR. SATHISH MODUGU MD

Table of content: DR. SATHISH MODUGU MD (NPI 1992705859)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1992705859 NPI number — DR. SATHISH MODUGU MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MODUGU
Provider First Name:
SATHISH
Provider Middle Name:
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1992705859
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/08/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
280 N CENTRAL AVE
Provider Second Line Business Mailing Address:
SUITE 204
Provider Business Mailing Address City Name:
HARTSDALE
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
10530-1832
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
914-681-9750
Provider Business Mailing Address Fax Number:
914-681-9755

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
280 N CENTRAL AVE
Provider Second Line Business Practice Location Address:
SUITE 204
Provider Business Practice Location Address City Name:
HARTSDALE
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
10530-1832
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
914-681-9750
Provider Business Practice Location Address Fax Number:
914-681-9755
Provider Enumeration Date:
07/21/2005

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 208VP0014X , with the licence number:  202468 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)