Provider Demographics
NPI:1578567913
Name:MODJTABAI, KHODADAD (MD)
Entity Type:Individual
Prefix:DR
First Name:KHODADAD
Middle Name:
Last Name:MODJTABAI
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 1:9784 OLD ANNAPOLIS RD
Mailing Address - Street 2:
Mailing Address - City:ELLICOTT CITY
Mailing Address - State:MD
Mailing Address - Zip Code:21042-6327
Mailing Address - Country:US
Mailing Address - Phone:410-997-1336
Mailing Address - Fax:410-997-1636
Practice Address - Street 1:10802 HICKORY RIDGE RD
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:MD
Practice Address - Zip Code:21044-3622
Practice Address - Country:US
Practice Address - Phone:301-997-1336
Practice Address - Fax:410-997-1636
Is Sole Proprietor?:No
Enumeration Date:2005-06-13
Last Update Date:2012-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDDOO61559174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDMD0200488OtherTRICARE
MD1013399OtherELDER HEALTH
MD243508OtherKAISER
MDP00287135OtherRAILROAD
MD243208OtherAMERIGROUP
MD5125212OtherMAMSI
MD9200455OtherEVERCARE
NC7615905Medicaid
DCN1510002OtherBLUE CROSS FEDERAL
VA1013399OtherFIRST HEALTH
MD2426820OtherUNITED HEALTHCARE
MD243208OtherAMERICAID
MD404889000Medicaid
MD7305576OtherAETNA OTHER
MD1142253OtherAETNA HMO
MD126480OtherJOHNS HOPKINS
MD3059165OtherCIGNA
MD5701OtherELDER HEALTH
DC036555600Medicaid
MD410823OtherAMERICHOICE
MD5125212OtherALLIANCE
MD64167401OtherBLUE CROSS OF MARYLAND
MD7305576OtherAETNA OTHER
MD243208OtherAMERICAID