Basic Information
Provider Information
NPI: 1003012477
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: MODRYKAMIEN
FirstName: ARIEL
MiddleName: MARCELO
NamePrefix: DR.
NameSuffix:  
Credential: M.D.
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 3600 GASTON AVE
Address2: WADLEY TOWER, SUITE 960
City: DALLAS
State: TX
PostalCode: 752461800
CountryCode: US
TelephoneNumber: 4029726078
FaxNumber:  
Practice Location
Address1: 3600 GASTON AVE
Address2: WADLEY TOWER, SUITE 960
City: DALLAS
State: TX
PostalCode: 752461800
CountryCode: US
TelephoneNumber: 4029726078
FaxNumber:  
Other Information
ProviderEnumerationDate: 06/22/2007
LastUpdateDate: 12/16/2014
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: M
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: N
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
207RC0200XP8278TXN Allopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
207RP1001XP8278TXY Allopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease

ID Information
IDTypeStateIssuerDescription
33737220105TX MEDICAID


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