Provider Demographics
NPI:1144285669
Name:MODI, PRAVEEN KUMAR (MD)
Entity type:Individual
Prefix:DR
First Name:PRAVEEN
Middle Name:KUMAR
Last Name:MODI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:990 W ANN ARBOR TRL
Mailing Address - Street 2:SUITE 102
Mailing Address - City:PLYMOUTH
Mailing Address - State:MI
Mailing Address - Zip Code:48170-6204
Mailing Address - Country:US
Mailing Address - Phone:734-414-1088
Mailing Address - Fax:734-414-1095
Practice Address - Street 1:990 W ANN ARBOR TRL
Practice Address - Street 2:SUITE 102
Practice Address - City:PLYMOUTH
Practice Address - State:MI
Practice Address - Zip Code:48170-6204
Practice Address - Country:US
Practice Address - Phone:734-414-1088
Practice Address - Fax:734-414-1095
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-18
Last Update Date:2015-03-03
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MIPM069773207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIP10850002Medicare ID - Type Unspecified
MIH22174Medicare UPIN
MIP10850002Medicare ID - Type Unspecified
MI4620532Medicaid