Healthcare Provider Details

I. General information

NPI: 1437109709
Provider Name (Legal Business Name): BRIAN W WISTOW M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/10/2006
Last Update Date: 03/01/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

600 COFFEE RD
MODESTO CA
95355-4201
US

IV. Provider business mailing address

600 COFFEE RD
MODESTO CA
95355-4201
US

V. Phone/Fax

Practice location:
  • Phone: 209-524-1211
  • Fax:
Mailing address:
  • Phone: 209-524-1211
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085B0100X
TaxonomyBody Imaging Physician
License NumberA33568
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberA33568
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code2085U0001X
TaxonomyDiagnostic Ultrasound Physician
License NumberA33568
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: