Provider Demographics
NPI:1689894578
Name:MODAK, PREMA (MD)
Entity Type:Individual
Prefix:DR
First Name:PREMA
Middle Name:
Last Name:MODAK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3998 FAIR RIDGE DR STE 105
Mailing Address - Street 2:
Mailing Address - City:FAIRFAX
Mailing Address - State:VA
Mailing Address - Zip Code:22033-2980
Mailing Address - Country:US
Mailing Address - Phone:571-349-2191
Mailing Address - Fax:
Practice Address - Street 1:3998 FAIR RIDGE DR STE 105
Practice Address - Street 2:
Practice Address - City:FAIRFAX
Practice Address - State:VA
Practice Address - Zip Code:22033-2980
Practice Address - Country:US
Practice Address - Phone:571-349-2191
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-26
Last Update Date:2019-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0070139207W00000X
VA0101240540207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology