Healthcare Provider Details

I. General information

NPI: 1366547796
Provider Name (Legal Business Name): MODESTO PEDIATRICS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/13/2006
Last Update Date: 08/16/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3109 COFFEE RD STE A
MODESTO CA
95355-1766
US

IV. Provider business mailing address

PO BOX 578202
MODESTO CA
95357-8202
US

V. Phone/Fax

Practice location:
  • Phone: 209-522-0001
  • Fax: 209-549-7077
Mailing address:
  • Phone: 209-522-0001
  • Fax: 209-549-7077

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberG83542
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberG68634
License Number StateCA

VIII. Authorized Official

Name: ANN MARIE TRUSCELLO
Title or Position: PRESIDENT
Credential: MD
Phone: 209-522-0001