Basic Information
| Provider Information | |||||||||
| NPI: | 1659630671 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MODH | ||||||||
| FirstName: | AMI | ||||||||
| MiddleName: | SONIA | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7703 FLOYD CURL DR | ||||||||
| Address2: | MC7977 | ||||||||
| City: | SAN ANTONIO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 782293901 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2104509000 | ||||||||
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| Practice Location | |||||||||
| Address1: | 4502 MEDICAL DR | ||||||||
| Address2: | |||||||||
| City: | SAN ANTONIO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 782294402 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2105675600 | ||||||||
| FaxNumber: | 2105676418 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/11/2012 | ||||||||
| LastUpdateDate: | 09/24/2013 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | OT012696 | PA | N | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085R0202X | P3932 | TX | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 302798901 | 05 | TX | MEDICAID |