1578567913 NPI number — DR. KHODADAD MODJTABAI M.D.

Table of content: DR. KHODADAD MODJTABAI M.D. (NPI 1578567913)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1578567913 NPI number — DR. KHODADAD MODJTABAI M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MODJTABAI
Provider First Name:
KHODADAD
Provider Middle Name:
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D.
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:
1578567913
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/23/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
9784 OLD ANNAPOLIS RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ELLICOTT CITY
Provider Business Mailing Address State Name:
MD
Provider Business Mailing Address Postal Code:
21042-6327
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
410-997-1336
Provider Business Mailing Address Fax Number:
410-997-1636

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
10802 HICKORY RIDGE RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
COLUMBIA
Provider Business Practice Location Address State Name:
MD
Provider Business Practice Location Address Postal Code:
21044-3622
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
301-997-1336
Provider Business Practice Location Address Fax Number:
410-997-1636
Provider Enumeration Date:
06/13/2005

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: 174400000X , with the licence number:  DOO61559 , registered in the state of MD ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: MD0200488 . This is a "TRICARE" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".
  • Identifier: 1013399 . This is a "ELDER HEALTH" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".
  • Identifier: 243508 . This is a "KAISER" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".
  • Identifier: P00287135 . This is a "RAILROAD" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".
  • Identifier: 243208 . This is a "AMERIGROUP" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".
  • Identifier: 5125212 . This is a "MAMSI" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".
  • Identifier: 9200455 . This is a "EVERCARE" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".
  • Identifier: 7615905 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".
  • Identifier: N1510002 . This is a "BLUE CROSS FEDERAL" identifier , issued by the state of ( DC ) . This identifiers is of the category "OTHER".
  • Identifier: 1013399 . This is a "FIRST HEALTH" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 2426820 . This is a "UNITED HEALTHCARE" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".
  • Identifier: 243208 . This is a "AMERICAID" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".
  • Identifier: 404889000 , issued by the state of ( MD ) . This identifiers is of the category "MEDICAID".
  • Identifier: 7305576 . This is a "AETNA OTHER" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".
  • Identifier: 1142253 . This is a "AETNA HMO" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".
  • Identifier: 126480 . This is a "JOHNS HOPKINS" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".
  • Identifier: 3059165 . This is a "CIGNA" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".
  • Identifier: 5701 . This is a "ELDER HEALTH" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".
  • Identifier: 036555600 , issued by the state of ( DC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 410823 . This is a "AMERICHOICE" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".




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