Healthcare Provider Details

I. General information

NPI: 1124328430
Provider Name (Legal Business Name): MODAR SUKKARIEH M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/02/2010
Last Update Date: 08/27/2024
Certification Date: 08/27/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 LONGWOOD AVE
BOSTON MA
02115-5724
US

IV. Provider business mailing address

300 LONGWOOD AVE
BOSTON MA
02115-5724
US

V. Phone/Fax

Practice location:
  • Phone: 617-355-6000
  • Fax:
Mailing address:
  • Phone: 617-355-6000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number259994
License Number StateMA
# 2
Primary TaxonomyY
Taxonomy Code207RA0401X
TaxonomyAddiction Medicine (Internal Medicine) Physician
License Number259994
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: