Provider Demographics
NPI:1447274840
Name:MODLY, CHARLOTTE ELISABETH
Entity type:Individual
Prefix:DR
First Name:CHARLOTTE
Middle Name:ELISABETH
Last Name:MODLY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4 GLYNDON DR
Mailing Address - Street 2:SUITE 2G
Mailing Address - City:REISTERSTOWN
Mailing Address - State:MD
Mailing Address - Zip Code:21136-2000
Mailing Address - Country:US
Mailing Address - Phone:410-526-1300
Mailing Address - Fax:410-526-3316
Practice Address - Street 1:4 GLYNDON DR
Practice Address - Street 2:SUITE 2G
Practice Address - City:REISTERSTOWN
Practice Address - State:MD
Practice Address - Zip Code:21136-2000
Practice Address - Country:US
Practice Address - Phone:410-526-1300
Practice Address - Fax:410-526-3316
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD43457207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDCE64Medicare ID - Type Unspecified
MDF04055Medicare UPIN