Basic Information
| Provider Information | |||||||||
| NPI: | 1992813224 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MODICA | ||||||||
| FirstName: | JOHN | ||||||||
| MiddleName: | |||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 320 POMFRET ST | ||||||||
| Address2: | DAY KIMBALL HOSPITAL | ||||||||
| City: | PUTNAM | ||||||||
| State: | CT | ||||||||
| PostalCode: | 06260 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8609286541 | ||||||||
| FaxNumber: | 8609636372 | ||||||||
| Practice Location | |||||||||
| Address1: | 320 POMFRET ST | ||||||||
| Address2: | DAY KIMBALL HOSPITAL | ||||||||
| City: | PUTNAM | ||||||||
| State: | CT | ||||||||
| PostalCode: | 06260 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8609286541 | ||||||||
| FaxNumber: | 8609636372 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/28/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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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 | 207RC0000X | 26506CT | CT | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease |
No ID Information.