Healthcare Provider Details

I. General information

NPI: 1720903370
Provider Name (Legal Business Name): SAGAR MUKESH MODI M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/12/2026
Last Update Date: 09/04/2026
Certification Date: 08/12/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

MERCY ONE NORTHEAST IOWA FAMILY MEDICINE & RESIDENCY 2055 KIMBALL AVE. STE. 101
WATERLOO IA
50702
US

IV. Provider business mailing address

MERCY ONE NORTHEAST IOWA FAMILY MEDICINE 2055 KIMBALL AVE. SUITE 101
WATERLOO IA
50702
US

V. Phone/Fax

Practice location:
  • Phone: 319-272-2112
  • Fax: 319-272-2107
Mailing address:
  • Phone: 319-272-2112
  • Fax: 319-272-2107

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberR14048
License Number StateIA
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: