Healthcare Provider Details

I. General information

NPI: 1205367000
Provider Name (Legal Business Name): MILAD MODARRESI
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/23/2017
Last Update Date: 07/07/2022
Certification Date: 07/07/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 BURLINGTON RD
JACKSON OH
45640-9360
US

IV. Provider business mailing address

1600 MEDICAL CENTER DR STE 2000
HUNTINGTON WV
25701-3656
US

V. Phone/Fax

Practice location:
  • Phone: 740-288-4625
  • Fax:
Mailing address:
  • Phone: 304-691-1282
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number35.144058
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: