Healthcare Provider Details

I. General information

NPI: 1831169721
Provider Name (Legal Business Name): DWIGHT CORDERO MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/24/2006
Last Update Date: 11/19/2020
Certification Date: 11/19/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1524 MCHENRY AVE STE 520
MODESTO CA
95350-4572
US

IV. Provider business mailing address

1524 MCHENRY AVE STE 520
MODESTO CA
95350-4572
US

V. Phone/Fax

Practice location:
  • Phone: 209-527-5555
  • Fax: 209-527-7630
Mailing address:
  • Phone: 209-527-5555
  • Fax: 209-527-7630

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207SG0201X
TaxonomyClinical Genetics (M.D.) Physician
License Number77370
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: