Provider Demographics
NPI:1619592698
Name:MODI, KHUSHBOO KIRITBHAI (MBBS)
Entity Type:Individual
Prefix:
First Name:KHUSHBOO
Middle Name:KIRITBHAI
Last Name:MODI
Suffix:
Gender:F
Credentials:MBBS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:120 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:DANBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06810-7834
Mailing Address - Country:US
Mailing Address - Phone:203-743-9760
Mailing Address - Fax:
Practice Address - Street 1:120 MAIN ST
Practice Address - Street 2:
Practice Address - City:DANBURY
Practice Address - State:CT
Practice Address - Zip Code:06810-7834
Practice Address - Country:US
Practice Address - Phone:203-743-9760
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-15
Last Update Date:2023-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CT74917208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program