MEDICARE: DPMMODLINPRIA LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	213ES0103X	Foot & Ankle Surgery Podiatrist	073866	IA

General Provider Information

NPI Number	:	1942614367
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DPMMODLINPRIA LLC

Provider Business Mailing Address
First Line	:	1111 E ARMY POST RD
Second Line	:	SUITE 470
City	:	DES MOINES
State	:	IA
Zip	:	50315-5970
Country	:	US
Telephone Number	:	515-244-0633
Fax Number	:	515-244-2412

Provider Business Practice Location Address
First Line	:	1111 E ARMY POST RD
Second Line	:	SUITE 470
City	:	DES MOINES
State	:	IA
Zip	:	50315-5970
Country	:	US
Telephone Number	:	515-244-0633
Fax Number	:	515-244-2412

Authorized Official
Title or Position	:	OWNER
Name	:	JOSHUA RAY MODLIN
Credential	:	DPM
Telephone Number	:	515-244-0633

Provider Enumeration Date	:	06/13/2014
Last Update Date	:	06/13/2014

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Directions to “DPMMODLINPRIA LLC ” Practice Location

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