Basic Information
| Provider Information | |||||||||
| NPI: | 1528072733 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MODUGNO | ||||||||
| FirstName: | ROBERT | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 9260 W SUNSET RD | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | LAS VEGAS | ||||||||
| State: | NV | ||||||||
| PostalCode: | 891484858 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7022553547 | ||||||||
| FaxNumber: | 7029212419 | ||||||||
| Practice Location | |||||||||
| Address1: | 9260 W SUNSET RD | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | LAS VEGAS | ||||||||
| State: | NV | ||||||||
| PostalCode: | 891484858 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7022553547 | ||||||||
| FaxNumber: | 7029212419 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/27/2006 | ||||||||
| LastUpdateDate: | 02/01/2017 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207VG0400X | 029496 | GA | N | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | Gynecology | 207VX0000X | 029496 | GA | N | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | Obstetrics | 207VX0000X | 16437 | NV | Y | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | Obstetrics |
ID Information
| ID | Type | State | Issuer | Description | 1439X | 01 | NC | BLUE CROSS BLUE SHIELD | OTHER | 4134092 | 01 | GA | UNITED HEALTHCARE | OTHER | 4134092 | 01 | GA | AETNA | OTHER | P00605634 | 01 | NC | RAILROAD MEDICARE | OTHER | 000453274S | 05 | GA | MEDICAID | 3047867 | 01 | GA | UNITED HEALTHCARE | OTHER | 5905360 | 05 | NC | MEDICAID | 202I164773 | 01 | GA | MEDICARE | OTHER | 000453274H | 05 | GA | MEDICAID | 6581 | 01 | GA | COVENTRY | OTHER | 0762454 | 01 | NC | CIGNA | OTHER |