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General NPI Number Information
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NPI Number | 1679611842
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Entity Type | Individual
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Provider Name | POONAM MODHA MD
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Gender | Female
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Dates
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Enumeration Date | 02/01/2007
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Last Update Date | 04/16/2025
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Provider Practice Location Address
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Address Line | 455 TOLL GATE RD PSYCHIATRY LIAISON CLINIC
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City | WARWICK
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State | RI
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Zip | 02886
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Country | US
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Telephone | 401-737-7010
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Fax |
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Provider Business Mailing Address
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Address Line | 455 TOLL GATE RD PRC AND CREDENTIALING
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City | WARWICK
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State | RI
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Zip | 02886-2759
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Country | US
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Telephone | 401-273-0641
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Fax | 401-273-2919
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2084P0800X
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Taxonomy Name | Psychiatry Physician
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License Number | MD12839
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License Number State | RI
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