Provider Demographics
NPI:1871683326
Name:MODIC, FRANK EDWARD (MD)
Entity type:Individual
Prefix:
First Name:FRANK
Middle Name:EDWARD
Last Name:MODIC
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:PO BOX 5651
Mailing Address - Street 2:
Mailing Address - City:ORANGE
Mailing Address - State:CA
Mailing Address - Zip Code:92863-5651
Mailing Address - Country:US
Mailing Address - Phone:714-571-5000
Mailing Address - Fax:714-571-5055
Practice Address - Street 1:121 SOTOYOME ST
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95405-4823
Practice Address - Country:US
Practice Address - Phone:707-546-4062
Practice Address - Fax:707-525-4097
Is Sole Proprietor?:No
Enumeration Date:2006-10-13
Last Update Date:2014-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG564912085U0001X, 2085N0904X, 2085B0100X, 2085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No2085U0001XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Ultrasound
No2085N0904XAllopathic & Osteopathic PhysiciansRadiologyNuclear Radiology
No2085B0100XAllopathic & Osteopathic PhysiciansRadiologyBody Imaging
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G564910Medicaid
E24948Medicare UPIN
CACA119047Medicare PIN
00G564910Medicare ID - Type Unspecified