Individual
JOHN GREGORY MODRALL
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
MD
Contact information
Practice address
5323 HARRY HINES BLVD, DALLAS, TX 75390-7208
(214) 645-0538
(214) 645-0546
Mailing address
PO BOX 845347, DALLAS, TX 75284-5347
(214) 645-0545
(214) 645-0546
Taxonomy
Speciality
Code
Description
License number
State
208600000X
Surgery Physician
K6159
TX
2086S0129X
Vascular Surgery Physician
E-7074
AR
2086S0129X
Vascular Surgery Physician
Primary
K6159
TX
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
106174903
—
TX
01
—
8D1525
MEDICARE
TX
Enumeration date
10/25/2006
Last updated
10/19/2015
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