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General NPI Number Information
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NPI Number | 1578567913
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Entity Type | Individual
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Provider Name | KHODADAD MODJTABAI M.D.
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Gender | Male
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Dates
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Enumeration Date | 06/13/2005
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Last Update Date | 10/23/2012
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Provider Practice Location Address
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Address Line | 10802 HICKORY RIDGE RD
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City | COLUMBIA
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State | MD
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Zip | 21044-3622
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Country | US
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Telephone | 301-997-1336
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Fax | 410-997-1636
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Provider Business Mailing Address
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Address Line | 9784 OLD ANNAPOLIS RD
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City | ELLICOTT CITY
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State | MD
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Zip | 21042-6327
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Country | US
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Telephone | 410-997-1336
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Fax | 410-997-1636
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 174400000X
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Taxonomy Name | Specialist
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License Number | DOO61559
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License Number State | MD
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