Basic Information
| Provider Information | |||||||||
| NPI: | 1740215631 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MODAK | ||||||||
| FirstName: | RAJ | ||||||||
| MiddleName: | K | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 9805 | ||||||||
| Address2: | 300 GEORGE ST 6TH FLR | ||||||||
| City: | NEW HAVEN | ||||||||
| State: | CT | ||||||||
| PostalCode: | 065360805 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2037857998 | ||||||||
| FaxNumber: | 2037856414 | ||||||||
| Practice Location | |||||||||
| Address1: | 800 HOWARD AVE | ||||||||
| Address2: | YALE PHYSICIANS BLDG | ||||||||
| City: | NEW HAVEN | ||||||||
| State: | CT | ||||||||
| PostalCode: | 065191369 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2037852140 | ||||||||
| FaxNumber: | 2037856414 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/11/2006 | ||||||||
| LastUpdateDate: | 09/16/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/16/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | 038177 | CT | N | Allopathic & Osteopathic Physicians | Anesthesiology | 207L00000X | ME157402 | FL | Y | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | 001381772 | 05 | CT | MEDICAID |