Healthcare Provider Details

I. General information

NPI: 1245594142
Provider Name (Legal Business Name): ANJALI MODI MANDER M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: ANJALI MODI MD

II. Dates (important events)

Enumeration Date: 06/26/2012
Last Update Date: 09/17/2026
Certification Date: 09/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 MICHIGAN ST NE
GRAND RAPIDS MI
49503
US

IV. Provider business mailing address

3264 N EVERGREEN DR NE
GRAND RAPIDS MI
49525-9746
US

V. Phone/Fax

Practice location:
  • Phone: 616-391-1609
  • Fax:
Mailing address:
  • Phone: 616-363-7339
  • Fax: 616-631-5828

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number4301101534
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number347554
License Number StateNY
# 3
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number4301101534
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: