MEDICARE: DR. KHODADAD MODJTABAI M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	174400000X	Specialist	DOO61559	MD

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MD0200488	OTHER	MD	TRICARE
2	1013399	OTHER	MD	ELDER HEALTH
3	243508	OTHER	MD	KAISER
4	P00287135	OTHER	MD	RAILROAD
5	243208	OTHER	MD	AMERIGROUP
6	5125212	OTHER	MD	MAMSI
7	9200455	OTHER	MD	EVERCARE
8	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
9	N1510002	OTHER	DC	BLUE CROSS FEDERAL
10	1013399	OTHER	VA	FIRST HEALTH
11	2426820	OTHER	MD	UNITED HEALTHCARE
12	243208	OTHER	MD	AMERICAID
13	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
14	7305576	OTHER	MD	AETNA OTHER
15	1142253	OTHER	MD	AETNA HMO
16	126480	OTHER	MD	JOHNS HOPKINS
17	3059165	OTHER	MD	CIGNA
18	5701	OTHER	MD	ELDER HEALTH
19	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
20	410823	OTHER	MD	AMERICHOICE
21	5125212	OTHER	MD	ALLIANCE
22	64167401	OTHER	MD	BLUE CROSS OF MARYLAND

General Provider Information

NPI Number	:	1578567913
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. KHODADAD MODJTABAI M.D.

Provider Business Mailing Address
First Line	:	9784 OLD ANNAPOLIS RD
Second Line	:
City	:	ELLICOTT CITY
State	:	MD
Zip	:	21042-6327
Country	:	US
Telephone Number	:	410-997-1336
Fax Number	:	410-997-1636

Provider Business Practice Location Address
First Line	:	10802 HICKORY RIDGE RD
Second Line	:
City	:	COLUMBIA
State	:	MD
Zip	:	21044-3622
Country	:	US
Telephone Number	:	301-997-1336
Fax Number	:	410-997-1636

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/13/2005
Last Update Date	:	10/23/2012

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