Basic Information
| Provider Information | |||||||||
| NPI: | 1669414942 | ||||||||
| EntityType: | 1 | ||||||||
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| LastName: | MODY | ||||||||
| FirstName: | MILAN | ||||||||
| MiddleName: | G | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7925 YOUREE DR | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | SHREVEPORT | ||||||||
| State: | LA | ||||||||
| PostalCode: | 711055127 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3182123610 | ||||||||
| FaxNumber: | 3182123709 | ||||||||
| Practice Location | |||||||||
| Address1: | 7925 YOUREE DR | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | SHREVEPORT | ||||||||
| State: | LA | ||||||||
| PostalCode: | 711055127 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3182123610 | ||||||||
| FaxNumber: | 3182123709 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/12/2006 | ||||||||
| LastUpdateDate: | 08/18/2008 | ||||||||
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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 | 207XS0117X | 201245 | LA | Y | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Orthopaedic Surgery of the Spine | 207XS0117X | M1943 | TX | N | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Orthopaedic Surgery of the Spine | 207X00000X | 201245 | LA | N | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |
ID Information
| ID | Type | State | Issuer | Description | 1457167 | 05 | LA | MEDICAID |