Healthcare Provider Details

I. General information

NPI: 1447423769
Provider Name (Legal Business Name): PHILIP MODAYIL M.D
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/08/2008
Last Update Date: 04/08/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

208 ROANOKE AVE
RIVERHEAD NY
11901-2706
US

IV. Provider business mailing address

790 PARK AVE
HUNTINGTON NY
11743-4516
US

V. Phone/Fax

Practice location:
  • Phone: 631-369-0104
  • Fax: 631-369-5433
Mailing address:
  • Phone: 631-427-3700
  • Fax: 631-427-0287

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberNY127026
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: