Provider Demographics
NPI:1811296684
Name:MODI, VIRAJ INDRAVADAN (DO)
Entity type:Individual
Prefix:
First Name:VIRAJ
Middle Name:INDRAVADAN
Last Name:MODI
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:UCONN MEDICAL GROUP
Mailing Address - Street 2:263 FARMINGTON AVENUE
Mailing Address - City:FARMINGTON
Mailing Address - State:CT
Mailing Address - Zip Code:06030-0001
Mailing Address - Country:US
Mailing Address - Phone:860-679-4477
Mailing Address - Fax:860-679-4474
Practice Address - Street 1:UCONN MEDICAL GROUP
Practice Address - Street 2:263 FARMINGTON AVENUE
Practice Address - City:FARMINGTON
Practice Address - State:CT
Practice Address - Zip Code:06030-0001
Practice Address - Country:US
Practice Address - Phone:860-679-4477
Practice Address - Fax:860-679-4474
Is Sole Proprietor?:No
Enumeration Date:2011-03-19
Last Update Date:2022-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS12190207R00000X
CT55017207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL14V1LOtherBLUE CROSS BLUE SHIELD
FL012203500Medicaid
FLP01433318Medicare PIN
FL012203500Medicaid