Healthcare Provider Details

I. General information

NPI: 1912647686
Provider Name (Legal Business Name): VIRAJ DEVANG MODI
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/31/2022
Last Update Date: 08/25/2026
Certification Date: 08/25/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

28 CRESCENT ST
MIDDLETOWN CT
06457-3650
US

IV. Provider business mailing address

28 CRESCENT ST
MIDDLETOWN CT
06457-3650
US

V. Phone/Fax

Practice location:
  • Phone: 860-358-5322
  • Fax: 860-358-6094
Mailing address:
  • Phone: 860-358-5322
  • Fax: 860-358-6094

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number86275
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: