Healthcare Provider Details

I. General information

NPI: 1538470257
Provider Name (Legal Business Name): DEVANSHI MODY M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/28/2010
Last Update Date: 03/11/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

841 PRUDENTIAL DR 10TH FLOOR
JACKSONVILLE FL
32207-8329
US

IV. Provider business mailing address

PO BOX 41113
JACKSONVILLE FL
32203-1113
US

V. Phone/Fax

Practice location:
  • Phone: 904-398-5404
  • Fax: 904-391-5595
Mailing address:
  • Phone: 904-376-4400
  • Fax: 904-391-5595

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License NumberME120949
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: