Healthcare Provider Details

I. General information

NPI: 1215639927
Provider Name (Legal Business Name): NICHOLAS ALAN MODEST MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/20/2023
Last Update Date: 07/15/2026
Certification Date: 07/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

801 MASSACHUSETTS AVE CROSSTOWN 2
BOSTON MA
02118-2605
US

IV. Provider business mailing address

960 MASSACHUSETTS AVE STE 2
BOSTON MA
02118-2690
US

V. Phone/Fax

Practice location:
  • Phone: 617-414-7399
  • Fax: 617-414-4676
Mailing address:
  • Phone: 617-414-7399
  • Fax: 617-414-4676

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number1025909
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: