Healthcare Provider Details

I. General information

NPI: 1578567913
Provider Name (Legal Business Name): KHODADAD MODJTABAI M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/13/2005
Last Update Date: 10/23/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10802 HICKORY RIDGE RD
COLUMBIA MD
21044-3622
US

IV. Provider business mailing address

9784 OLD ANNAPOLIS RD
ELLICOTT CITY MD
21042-6327
US

V. Phone/Fax

Practice location:
  • Phone: 301-997-1336
  • Fax: 410-997-1636
Mailing address:
  • Phone: 410-997-1336
  • Fax: 410-997-1636

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License NumberDOO61559
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: