Provider Demographics
NPI:1518157445
Name:MODI, BIJAL SHAH (PA C)
Entity Type:Individual
Prefix:
First Name:BIJAL
Middle Name:SHAH
Last Name:MODI
Suffix:
Gender:F
Credentials:PA C
Other - Prefix:
Other - First Name:BIJAL
Other - Middle Name:R
Other - Last Name:SHAH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA C
Mailing Address - Street 1:381 PARK AVE S
Mailing Address - Street 2:SUITE 1020
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10016-8806
Mailing Address - Country:US
Mailing Address - Phone:212-260-6078
Mailing Address - Fax:212-260-6185
Practice Address - Street 1:381 PARK AVE S
Practice Address - Street 2:SUITE 1020
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10016-8806
Practice Address - Country:US
Practice Address - Phone:212-260-6078
Practice Address - Fax:212-260-6185
Is Sole Proprietor?:No
Enumeration Date:2007-07-26
Last Update Date:2009-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036 0716442088P0231X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2088P0231XAllopathic & Osteopathic PhysiciansUrologyPediatric Urology
Provider Identifiers
StateIdentifier IDID TypeIssuer
E96107Medicare UPIN