Healthcare Provider Details

I. General information

NPI: 1992747547
Provider Name (Legal Business Name): MODESTO RADIOLOGICAL MEDICAL GROUP, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/11/2006
Last Update Date: 12/09/2022
Certification Date: 12/09/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1524 MCHENRY AVE SUITE 100
MODESTO CA
95350-4500
US

IV. Provider business mailing address

1524 MCHENRY AVE STE 420
MODESTO CA
95350-4567
US

V. Phone/Fax

Practice location:
  • Phone: 209-342-5920
  • Fax:
Mailing address:
  • Phone: 209-342-5920
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085B0100X
TaxonomyBody Imaging Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2085N0700X
TaxonomyNeuroradiology Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code2085R0204X
TaxonomyVascular & Interventional Radiology Physician
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number
License Number State

VIII. Authorized Official

Name: MICHAEL ZEPPA
Title or Position: PRESIDENT
Credential:
Phone: 209-342-5920