Healthcare Provider Details

I. General information

NPI: 1790974863
Provider Name (Legal Business Name): PHILIPP ANDREAS SACK M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/15/2007
Last Update Date: 08/27/2021
Certification Date: 08/27/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1601 CUMMINS DR STE D
MODESTO CA
95358-6411
US

IV. Provider business mailing address

1601 CUMMINS DR STE D
MODESTO CA
95358-6411
US

V. Phone/Fax

Practice location:
  • Phone: 510-900-3125
  • Fax: 504-988-4270
Mailing address:
  • Phone: 510-900-3125
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberC133712
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number15976R
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: