Provider Demographics
NPI:1528007143
Name:MODI, RAJU (MD)
Entity Type:Individual
Prefix:
First Name:RAJU
Middle Name:
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 1:6525 POWERS BLVD
Mailing Address - Street 2:301
Mailing Address - City:PARMA
Mailing Address - State:OH
Mailing Address - Zip Code:44129-5461
Mailing Address - Country:US
Mailing Address - Phone:440-882-0075
Mailing Address - Fax:440-882-2092
Practice Address - Street 1:6525 POWERS BLVD
Practice Address - Street 2:301
Practice Address - City:PARMA
Practice Address - State:OH
Practice Address - Zip Code:44129-5461
Practice Address - Country:US
Practice Address - Phone:440-882-0075
Practice Address - Fax:440-882-2092
Is Sole Proprietor?:No
Enumeration Date:2006-06-06
Last Update Date:2021-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35074487207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2080206Medicaid
OH060054639OtherRAILROAD MEDICARE
OH000000130054OtherANTHEM BC/BS
OHMO0854337Medicare PIN
OH060054639OtherRAILROAD MEDICARE
OHG76970Medicare UPIN
OH000000130054OtherANTHEM BC/BS