Provider Demographics
NPI:1942272745
Name:MODZELEWSKI, JOSEPH ROBERT (MD)
Entity type:Individual
Prefix:DR
First Name:JOSEPH
Middle Name:ROBERT
Last Name:MODZELEWSKI
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:PO BOX 30309
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29417-0309
Mailing Address - Country:US
Mailing Address - Phone:843-554-9300
Mailing Address - Fax:843-556-8780
Practice Address - Street 1:2435 FOREST DR
Practice Address - Street 2:C/O PROVIDENCE HOSPITAL
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29204-2026
Practice Address - Country:US
Practice Address - Phone:803-256-5336
Practice Address - Fax:803-256-5454
Is Sole Proprietor?:No
Enumeration Date:2006-02-06
Last Update Date:2008-02-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC19654207ZC0500X, 207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
No207ZC0500XAllopathic & Osteopathic PhysiciansPathologyCytopathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC196549Medicaid
G73252Medicare UPIN