Provider Demographics
NPI:1174674816
Name:MODI, ASHESH I (MD)
Entity type:Individual
Prefix:
First Name:ASHESH
Middle Name:I
Last Name:MODI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4745 OGLETOWN STANTON RD
Mailing Address - Street 2:MAP #1
Mailing Address - City:NEWARK
Mailing Address - State:DE
Mailing Address - Zip Code:19713-2067
Mailing Address - Country:US
Mailing Address - Phone:302-738-5300
Mailing Address - Fax:302-731-4822
Practice Address - Street 1:4745 OGLETOWN STANTON RD
Practice Address - Street 2:MAP #1
Practice Address - City:NEWARK
Practice Address - State:DE
Practice Address - Zip Code:19713-2067
Practice Address - Country:US
Practice Address - Phone:302-738-5300
Practice Address - Fax:302-731-4822
Is Sole Proprietor?:No
Enumeration Date:2007-01-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEC10005584174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
DE000944101Medicaid
DE003307G56Medicare ID - Type Unspecified
G19292Medicare UPIN