Healthcare Provider Details

I. General information

NPI: 1043331788
Provider Name (Legal Business Name): SHIRLEY ROSE RAMISCAL DOMINGO M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/02/2007
Last Update Date: 12/13/2021
Certification Date: 03/04/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1700 COFFEE RD
MODESTO CA
95355-2803
US

IV. Provider business mailing address

220 STANDIFORD AVE STE F
MODESTO CA
95350-1159
US

V. Phone/Fax

Practice location:
  • Phone: 209-526-4500
  • Fax:
Mailing address:
  • Phone: 209-661-4410
  • Fax: 209-579-5637

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number4301082981
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberMDR-5205
License Number StateHI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: