1811296684 NPI number — VIRAJ INDRAVADAN MODI D.O.

Table of content: VIRAJ INDRAVADAN MODI D.O. (NPI 1811296684)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1811296684 NPI number — VIRAJ INDRAVADAN MODI D.O.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MODI
Provider First Name:
VIRAJ
Provider Middle Name:
INDRAVADAN
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
D.O.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1811296684
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/29/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
UCONN MEDICAL GROUP
Provider Second Line Business Mailing Address:
263 FARMINGTON AVENUE
Provider Business Mailing Address City Name:
FARMINGTON
Provider Business Mailing Address State Name:
CT
Provider Business Mailing Address Postal Code:
06030-0001
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
860-679-4477
Provider Business Mailing Address Fax Number:
860-679-4474

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
UCONN MEDICAL GROUP
Provider Second Line Business Practice Location Address:
263 FARMINGTON AVENUE
Provider Business Practice Location Address City Name:
FARMINGTON
Provider Business Practice Location Address State Name:
CT
Provider Business Practice Location Address Postal Code:
06030-0001
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
860-679-4477
Provider Business Practice Location Address Fax Number:
860-679-4474
Provider Enumeration Date:
03/19/2011

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X , with the licence number:  OS12190 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207R00000X , with the licence number: 55017 , registered in the state of CT ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 14V1L . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 012203500 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2024 www.npivalidator.com