Provider Demographics
NPI:1124002324
Name:MODAK, RAJIV (MD)
Entity Type:Individual
Prefix:
First Name:RAJIV
Middle Name:
Last Name:MODAK
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 1:1500 W COMMERCE CT
Mailing Address - Street 2:BLDG 1
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85746-6031
Mailing Address - Country:US
Mailing Address - Phone:520-792-9890
Mailing Address - Fax:
Practice Address - Street 1:1500 W COMMERCE CT
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85746-6015
Practice Address - Country:US
Practice Address - Phone:520-670-3909
Practice Address - Fax:520-806-2625
Is Sole Proprietor?:No
Enumeration Date:2005-12-01
Last Update Date:2016-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ28426208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ527690Medicaid
AZ67526Medicare ID - Type Unspecified
AZH27021Medicare UPIN