Provider Demographics
NPI:1700886132
Name:MODI, KAUSHIK CHHAGANLAL (MD)
Entity Type:Individual
Prefix:
First Name:KAUSHIK
Middle Name:CHHAGANLAL
Last Name:MODI
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 1:449 MOUNT PLEASANT AVE
Mailing Address - Street 2:2ND FLOOR
Mailing Address - City:WEST ORANGE
Mailing Address - State:NJ
Mailing Address - Zip Code:07052-2723
Mailing Address - Country:US
Mailing Address - Phone:973-731-7868
Mailing Address - Fax:973-731-7907
Practice Address - Street 1:449 MOUNT PLEASANT AVE
Practice Address - Street 2:2ND FLOOR
Practice Address - City:WEST ORANGE
Practice Address - State:NJ
Practice Address - Zip Code:07052-2723
Practice Address - Country:US
Practice Address - Phone:973-731-7868
Practice Address - Fax:973-731-7907
Is Sole Proprietor?:No
Enumeration Date:2005-07-28
Last Update Date:2013-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA05857500207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ6957901Medicaid
NJF71220Medicare UPIN
NJ501158Medicare ID - Type Unspecified