Provider Demographics
NPI:1417414418
Name:MODI, KHUSHBU VIJAYKUMAR
Entity type:Individual
Prefix:
First Name:KHUSHBU
Middle Name:VIJAYKUMAR
Last Name:MODI
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2680 S WHITE RD
Mailing Address - Street 2:STE 200
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95148-2079
Mailing Address - Country:US
Mailing Address - Phone:408-274-0888
Mailing Address - Fax:
Practice Address - Street 1:2474 WILSON TER
Practice Address - Street 2:
Practice Address - City:UNION
Practice Address - State:NJ
Practice Address - Zip Code:07083-6543
Practice Address - Country:US
Practice Address - Phone:551-263-6141
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-02-26
Last Update Date:2020-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA299276225100000X
NY044115-1225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist