Healthcare Provider Details

I. General information

NPI: 1518073451
Provider Name (Legal Business Name): PRAKASHCHANDRA JIVRAMBHAI CHAUDHARI MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: PRAKASH J CHAUDHARI MD

II. Dates (important events)

Enumeration Date: 08/22/2006
Last Update Date: 06/12/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4301 N STAR WAY
MODESTO CA
95356
US

IV. Provider business mailing address

PO BOX 576768
MODESTO CA
95357-6768
US

V. Phone/Fax

Practice location:
  • Phone: 209-577-1200
  • Fax: 209-577-6517
Mailing address:
  • Phone: 209-577-1200
  • Fax: 209-577-6517

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207ZD0900X
TaxonomyDermatopathology (Pathology) Physician
License Number8960
License Number StateNV
# 2
Primary TaxonomyN
Taxonomy Code207ZP0102X
TaxonomyAnatomic Pathology & Clinical Pathology Physician
License Number8960
License Number StateNV
# 3
Primary TaxonomyY
Taxonomy Code207ZP0102X
TaxonomyAnatomic Pathology & Clinical Pathology Physician
License NumberC52642
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: