Basic Information
| Provider Information | |||||||||
| NPI: | 1811296684 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MODI | ||||||||
| FirstName: | VIRAJ | ||||||||
| MiddleName: | INDRAVADAN | ||||||||
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| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | UCONN MEDICAL GROUP | ||||||||
| Address2: | 263 FARMINGTON AVENUE | ||||||||
| City: | FARMINGTON | ||||||||
| State: | CT | ||||||||
| PostalCode: | 060300001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8606794477 | ||||||||
| FaxNumber: | 8606794474 | ||||||||
| Practice Location | |||||||||
| Address1: | UCONN MEDICAL GROUP | ||||||||
| Address2: | 263 FARMINGTON AVENUE | ||||||||
| City: | FARMINGTON | ||||||||
| State: | CT | ||||||||
| PostalCode: | 060300001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8606794477 | ||||||||
| FaxNumber: | 8606794474 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/19/2011 | ||||||||
| LastUpdateDate: | 09/29/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | OS12190 | FL | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207R00000X | 55017 | CT | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 14V1L | 01 | FL | BLUE CROSS BLUE SHIELD | OTHER | 012203500 | 05 | FL | MEDICAID |