Basic Information
| Provider Information | |||||||||
| NPI: | 1376514489 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MODI | ||||||||
| FirstName: | MAHESH | ||||||||
| MiddleName: | G | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 986 | ||||||||
| Address2: | |||||||||
| City: | WOODBRIDGE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 952580986 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2093399036 | ||||||||
| FaxNumber: | 2093391901 | ||||||||
| Practice Location | |||||||||
| Address1: | 2160 W GRANT LINE RD | ||||||||
| Address2: | SUITE 240 | ||||||||
| City: | TRACY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 953777330 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2098336118 | ||||||||
| FaxNumber: | 2098357999 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/27/2006 | ||||||||
| LastUpdateDate: | 01/20/2010 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RG0100X | A37333 | CA | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Gastroenterology |
ID Information
| ID | Type | State | Issuer | Description | 00A373330 | 05 | CA | MEDICAID |