Healthcare Provider Details

I. General information

NPI: 1275796286
Provider Name (Legal Business Name): YURATA GERWEL MODZELEWSKI MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/09/2008
Last Update Date: 07/09/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

105 POWERVILLE ROAD
BOONTON TWP NJ
07005
US

IV. Provider business mailing address

105 POWERVILLE ROAD
BOONTON TWP NJ
07005
US

V. Phone/Fax

Practice location:
  • Phone: 973-299-2903
  • Fax: 973-299-2903
Mailing address:
  • Phone: 973-299-2903
  • Fax: 973-299-2903

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number25MA03879000
License Number StateNJ

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: