Healthcare Provider Details

I. General information

NPI: 1235379207
Provider Name (Legal Business Name): BRIAN DAVID MODENA M.D., MSC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/03/2009
Last Update Date: 04/09/2025
Certification Date: 04/09/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9850 GENESEE AVE STE 710
LA JOLLA CA
92037-1218
US

IV. Provider business mailing address

9850 GENESEE AVE STE 710
LA JOLLA CA
92037-1218
US

V. Phone/Fax

Practice location:
  • Phone: 858-260-2977
  • Fax: 858-260-2978
Mailing address:
  • Phone: 858-260-2977
  • Fax: 858-260-2978

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberA103242
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code207RA0201X
TaxonomyAllergy & Immunology (Internal Medicine) Physician
License NumberA103242
License Number StateCA
# 3
Primary TaxonomyY
Taxonomy Code207K00000X
TaxonomyAllergy & Immunology Physician
License NumberA103242
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: