Healthcare Provider Details

I. General information

NPI: 1093069411
Provider Name (Legal Business Name): KISHORE KUMAR GADDAM M.D
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/07/2012
Last Update Date: 07/01/2025
Certification Date: 07/01/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1510 FLORIDA AVE
MODESTO CA
95350-4437
US

IV. Provider business mailing address

1510 FLORIDA AVE
MODESTO CA
95350-4437
US

V. Phone/Fax

Practice location:
  • Phone: 209-722-4842
  • Fax:
Mailing address:
  • Phone: 209-722-4842
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberC10025067
License Number StateDE
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberC201309
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: