Healthcare Provider Details

I. General information

NPI: 1952336851
Provider Name (Legal Business Name): MAHATHEP MATTHEW SRIKUREJA D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

Provider Other Name: MAHATHEP MATTHEW SRIKUREJA D.O.

II. Dates (important events)

Enumeration Date: 07/11/2006
Last Update Date: 02/02/2024
Certification Date: 02/02/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4601 DALE RD
MODESTO CA
95356-9718
US

IV. Provider business mailing address

PO BOX 4259
CERRITOS CA
90703-4259
US

V. Phone/Fax

Practice location:
  • Phone: 209-735-5000
  • Fax:
Mailing address:
  • Phone: 562-407-2080
  • Fax: 562-407-2082

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number20A7504
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: