Provider Demographics
NPI:1821551979
Name:MODUR, VIJAY (MD)
Entity Type:Individual
Prefix:DR
First Name:VIJAY
Middle Name:
Last Name:MODUR
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 1:50 BINNEY ST
Mailing Address - Street 2:
Mailing Address - City:CAMBRIDGE
Mailing Address - State:MA
Mailing Address - Zip Code:02142-1512
Mailing Address - Country:US
Mailing Address - Phone:508-308-6173
Mailing Address - Fax:
Practice Address - Street 1:3 SQUIRREL HILL RD
Practice Address - Street 2:
Practice Address - City:ACTON
Practice Address - State:MA
Practice Address - Zip Code:01720-2017
Practice Address - Country:US
Practice Address - Phone:610-409-8366
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-06
Last Update Date:2019-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2010013501207ZC0006X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZC0006XAllopathic & Osteopathic PhysiciansPathologyClinical Pathology