Healthcare Provider Details

I. General information

NPI: 1467533737
Provider Name (Legal Business Name): ASPEN FAMILY MEDICAL GROUP OF MODESTO, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/17/2006
Last Update Date: 08/13/2024
Certification Date: 08/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1130 COFFEE RD STE 10
MODESTO CA
95355-4228
US

IV. Provider business mailing address

1130 COFFEE RD STE 10
MODESTO CA
95355-4228
US

V. Phone/Fax

Practice location:
  • Phone: 209-522-9054
  • Fax: 209-522-2631
Mailing address:
  • Phone: 209-522-9054
  • Fax: 209-522-2631

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number State

VIII. Authorized Official

Name: MARIELA GUTIERREZ
Title or Position: CLINIC SUPERVISOR
Credential: MEDICAL ASSISTANT
Phone: 209-522-9054