Healthcare Provider Details

I. General information

NPI: 1043954225
Provider Name (Legal Business Name): BANSARI MODI
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/25/2022
Last Update Date: 04/15/2026
Certification Date: 04/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7165 COLFAX AVE
CUMMING GA
30040-3027
US

IV. Provider business mailing address

7165 COLFAX AVE
CUMMING GA
30040-3027
US

V. Phone/Fax

Practice location:
  • Phone: 678-990-3362
  • Fax: 678-341-9212
Mailing address:
  • Phone: 678-990-3362
  • Fax: 678-341-9212

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number105500
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: