Healthcare Provider Details

I. General information

NPI: 1619081890
Provider Name (Legal Business Name): NEHAL P MODH MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/18/2006
Last Update Date: 10/08/2024
Certification Date: 10/08/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1145B E GANNON DR
FESTUS MO
63028-2611
US

IV. Provider business mailing address

PO BOX 1125
MARYLAND HEIGHTS MO
63043-0125
US

V. Phone/Fax

Practice location:
  • Phone: 636-933-7673
  • Fax: 636-937-5001
Mailing address:
  • Phone: 314-432-2580
  • Fax: 314-432-0223

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2081P2900X
TaxonomyPain Medicine (Physical Medicine & Rehabilitation) Physician
License Number2004028055
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: