Provider Demographics
NPI:1902895733
Name:MODI, RAJENDRA KUMAR (MD)
Entity Type:Individual
Prefix:
First Name:RAJENDRA
Middle Name:KUMAR
Last Name:MODI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:55-44 METROPOLITAN AVENUE
Mailing Address - Street 2:
Mailing Address - City:RIDGEWOOD
Mailing Address - State:NY
Mailing Address - Zip Code:11385
Mailing Address - Country:US
Mailing Address - Phone:718-456-2020
Mailing Address - Fax:718-821-5342
Practice Address - Street 1:55-44 METROPOLITAN AVENUE
Practice Address - Street 2:
Practice Address - City:RIDGEWOOD
Practice Address - State:NY
Practice Address - Zip Code:11385
Practice Address - Country:US
Practice Address - Phone:718-456-2020
Practice Address - Fax:718-821-5342
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-14
Last Update Date:2011-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY154743174400000X, 207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY0773280Medicaid
NYDS376OtherOXFORD
NY74937OtherAETNA USHC
NYDS376OtherOXF
NY00773280Medicaid
NY86601Medicare PIN
NYA64913Medicare UPIN
NYDS376OtherOXFORD