Healthcare Provider Details

I. General information

NPI: 1033203740
Provider Name (Legal Business Name): MADHUP JOSHI MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/03/2006
Last Update Date: 09/10/2026
Certification Date: 09/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

721 RIVER DR STE A
FORT BRAGG CA
95437
US

IV. Provider business mailing address

721 RIVER DR STE A
FORT BRAGG CA
95437
US

V. Phone/Fax

Practice location:
  • Phone: 707-961-4631
  • Fax:
Mailing address:
  • Phone: 707-961-4631
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QA0401X
TaxonomyAddiction Medicine (Family Medicine) Physician
License NumberG55251
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: