Healthcare Provider Details

I. General information

NPI: 1245823822
Provider Name (Legal Business Name): RUPALI CHAITANYA MAHIDA NP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/16/2021
Last Update Date: 03/28/2025
Certification Date: 03/28/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1317 OAKDALE RD STE 440
MODESTO CA
95355-3364
US

IV. Provider business mailing address

1317 OAKDALE RD STE 440
MODESTO CA
95355-3364
US

V. Phone/Fax

Practice location:
  • Phone: 209-522-3362
  • Fax:
Mailing address:
  • Phone: 209-522-3362
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number95016695
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: