Provider Demographics
NPI:1144756305
Name:MODI, SURAJ
Entity Type:Individual
Prefix:DR
First Name:SURAJ
Middle Name:
Last Name:MODI
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:455 W WARREN AVE
Mailing Address - Street 2:
Mailing Address - City:LONGWOOD
Mailing Address - State:FL
Mailing Address - Zip Code:32750-4038
Mailing Address - Country:US
Mailing Address - Phone:407-262-2220
Mailing Address - Fax:407-834-5011
Practice Address - Street 1:455 W WARREN AVE
Practice Address - Street 2:
Practice Address - City:LONGWOOD
Practice Address - State:FL
Practice Address - Zip Code:32750-4038
Practice Address - Country:US
Practice Address - Phone:407-262-2220
Practice Address - Fax:407-834-5011
Is Sole Proprietor?:No
Enumeration Date:2017-05-10
Last Update Date:2022-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME1460612084P0800X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program