Healthcare Provider Details

I. General information

NPI: 1962059493
Provider Name (Legal Business Name): DIXITKUMAR N MODI MD PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/20/2019
Last Update Date: 02/23/2024
Certification Date: 10/11/2020
Deactivation Date: 02/20/2024
Reactivation Date: 02/23/2024

III. Provider practice location address

4350 N ATLANTIC AVE
COCOA BEACH FL
32931-3656
US

IV. Provider business mailing address

3003 TRASONA DR
MELBOURNE FL
32940-7670
US

V. Phone/Fax

Practice location:
  • Phone: 334-327-9530
  • Fax:
Mailing address:
  • Phone: 321-613-5352
  • Fax: 321-613-5356

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. DIXITKUMAR NAVINCHANDRA MODI
Title or Position: OWNER
Credential: MD
Phone: 334-327-9530