Basic Information
| Provider Information | |||||||||
| NPI: | 1235146648 | ||||||||
| EntityType: | 1 | ||||||||
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| LastName: | MODARRESIFAR | ||||||||
| FirstName: | HOMAYOUN | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2109 W MARKET ST STE 122 | ||||||||
| Address2: | ETSU, INNOVATION LABORATORY | ||||||||
| City: | JOHNSON CITY | ||||||||
| State: | TN | ||||||||
| PostalCode: | 376046024 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4234398000 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2109 W MARKET ST STE 122 | ||||||||
| Address2: | ETSU, INNOVATION LABORATORY | ||||||||
| City: | JOHNSON CITY | ||||||||
| State: | TN | ||||||||
| PostalCode: | 376046024 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4234398000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/01/2006 | ||||||||
| LastUpdateDate: | 05/13/2011 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207U00000X | 41198 | AZ | N | Allopathic & Osteopathic Physicians | Nuclear Medicine | 207UN0902X | A93513 | CA | N | Allopathic & Osteopathic Physicians | Nuclear Medicine | Nuclear Imaging & Therapy | 207UN0902X | N5255 | TX | N | Allopathic & Osteopathic Physicians | Nuclear Medicine | Nuclear Imaging & Therapy | 207UN0902X | MD0000046850 | TN | Y | Allopathic & Osteopathic Physicians | Nuclear Medicine | Nuclear Imaging & Therapy |
ID Information
| ID | Type | State | Issuer | Description | MD0000046850 | 01 | TN | TENNESSEE MEDICAL LICENSE | OTHER |