Healthcare Provider Details

I. General information

NPI: 1245075985
Provider Name (Legal Business Name): MANGPREET DOOL
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/26/2024
Last Update Date: 06/26/2024
Certification Date: 06/26/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2222 E ORANGEBURG AVE
MODESTO CA
95355-3399
US

IV. Provider business mailing address

815 AZORES LN
CERES CA
95307-7304
US

V. Phone/Fax

Practice location:
  • Phone: 209-622-0877
  • Fax:
Mailing address:
  • Phone: 209-345-8985
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number95030738
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: