Provider Demographics
NPI:1053758094
Name:MODZESKI, MARA C (MD)
Entity type:Individual
Prefix:
First Name:MARA
Middle Name:C
Last Name:MODZESKI
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 N ACADEMY AVE
Mailing Address - Street 2:
Mailing Address - City:DANVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:17822-4903
Mailing Address - Country:US
Mailing Address - Phone:570-271-6144
Mailing Address - Fax:
Practice Address - Street 1:132 ABIGAIL LN
Practice Address - Street 2:
Practice Address - City:PORT MATILDA
Practice Address - State:PA
Practice Address - Zip Code:16870-7153
Practice Address - Country:US
Practice Address - Phone:814-272-5011
Practice Address - Fax:814-272-6531
Is Sole Proprietor?:No
Enumeration Date:2013-05-31
Last Update Date:2020-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN58125207Y00000X
PAMD464929207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNH400165387Medicare PIN