Provider Demographics
NPI:1871551176
Name:MODY, DINA RUSTOM (MD)
Entity type:Individual
Prefix:
First Name:DINA
Middle Name:RUSTOM
Last Name:MODY
Suffix:
Gender:F
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:PO BOX 4701
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77210-4701
Mailing Address - Country:US
Mailing Address - Phone:713-441-3885
Mailing Address - Fax:713-441-3886
Practice Address - Street 1:6565 FANNIN ST
Practice Address - Street 2:MS205
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77030-2703
Practice Address - Country:US
Practice Address - Phone:713-394-6450
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-03
Last Update Date:2007-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXG1442207ZC0500X, 207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
No207ZC0500XAllopathic & Osteopathic PhysiciansPathologyCytopathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXP00317147Medicare PIN
TX8G9525Medicare PIN
E35382Medicare UPIN
TX8F3018Medicare PIN