Provider Demographics
NPI:1629077847
Name:MODI, JITENDRAKUMAR RAJNIKANT (MD)
Entity Type:Individual
Prefix:DR
First Name:JITENDRAKUMAR
Middle Name:RAJNIKANT
Last Name:MODI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:JITU
Other - Middle Name:RAJNI
Other - Last Name:MODI
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:250 WOOD RD
Mailing Address - Street 2:
Mailing Address - City:ANNAPOLIS
Mailing Address - State:MD
Mailing Address - Zip Code:21402-1257
Mailing Address - Country:US
Mailing Address - Phone:410-293-2273
Mailing Address - Fax:410-293-3264
Practice Address - Street 1:250 WOOD RD
Practice Address - Street 2:NHCL ANNAPOLIS (PEDIATRICS)
Practice Address - City:ANNAPOLIS
Practice Address - State:MD
Practice Address - Zip Code:21402-1257
Practice Address - Country:US
Practice Address - Phone:410-293-4414
Practice Address - Fax:410-293-3264
Is Sole Proprietor?:No
Enumeration Date:2005-07-19
Last Update Date:2010-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD64213208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDVAD000Medicare UPIN