Healthcare Provider Details

I. General information

NPI: 1588954929
Provider Name (Legal Business Name): MODESTO RADIOLOGY IMAGING, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/19/2011
Last Update Date: 08/28/2024
Certification Date: 08/28/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1524 MCHENRY AVE # 100
MODESTO CA
95350-4500
US

IV. Provider business mailing address

1524 MCHENRY AVE # 100
MODESTO CA
95350-4500
US

V. Phone/Fax

Practice location:
  • Phone: 209-577-4444
  • Fax: 209-527-2069
Mailing address:
  • Phone: 209-577-4444
  • Fax: 209-527-2069

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number
License Number State

VIII. Authorized Official

Name: JAIKUMAR KRISHNASWAMY
Title or Position: OFFICER/AUTHORIZED OFFICIAL
Credential:
Phone: 972-713-3500