Healthcare Provider Details

I. General information

NPI: 1235364258
Provider Name (Legal Business Name): MARY JESSIE SUMITHRA M.D
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/19/2009
Last Update Date: 12/13/2021
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4125 BANGS AVE
MODESTO CA
95356-8713
US

IV. Provider business mailing address

501 6TH ST APT 12-J
BROOKLYN NY
11215-3671
US

V. Phone/Fax

Practice location:
  • Phone: 209-557-1630
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberA105261
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: