Provider Demographics
NPI:1235146648
Name:MODARRESIFAR, HOMAYOUN (MD)
Entity type:Individual
Prefix:
First Name:HOMAYOUN
Middle Name:
Last Name:MODARRESIFAR
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2109 W MARKET ST STE 122
Mailing Address - Street 2:ETSU, INNOVATION LABORATORY
Mailing Address - City:JOHNSON CITY
Mailing Address - State:TN
Mailing Address - Zip Code:37604-6024
Mailing Address - Country:US
Mailing Address - Phone:423-439-8000
Mailing Address - Fax:
Practice Address - Street 1:2109 W MARKET ST STE 122
Practice Address - Street 2:ETSU, INNOVATION LABORATORY
Practice Address - City:JOHNSON CITY
Practice Address - State:TN
Practice Address - Zip Code:37604-6024
Practice Address - Country:US
Practice Address - Phone:423-439-8000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-01
Last Update Date:2011-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ41198207U00000X
CAA93513207UN0902X
TXN5255207UN0902X
TNMD0000046850207UN0902X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207UN0902XAllopathic & Osteopathic PhysiciansNuclear MedicineNuclear Imaging & Therapy
No207U00000XAllopathic & Osteopathic PhysiciansNuclear Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNMD0000046850OtherTENNESSEE MEDICAL LICENSE
AZZ126506Medicare PIN