Provider Demographics
NPI:1174098784
Name:MODY, MITAL ABHIJEET
Entity type:Individual
Prefix:
First Name:MITAL
Middle Name:ABHIJEET
Last Name:MODY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1843 W FETLOCK TRL
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85085-6359
Mailing Address - Country:US
Mailing Address - Phone:602-626-4021
Mailing Address - Fax:
Practice Address - Street 1:1843 W FETLOCK TRL
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85085-6359
Practice Address - Country:US
Practice Address - Phone:623-252-0892
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-10
Last Update Date:2018-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZS023617183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZS023617Medicaid