Healthcare Provider Details

I. General information

NPI: 1083497085
Provider Name (Legal Business Name): RAJESH SUPRA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/15/2023
Last Update Date: 08/15/2023
Certification Date: 08/15/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1400 FLORIDA AVE STE 102
MODESTO CA
95350-4446
US

IV. Provider business mailing address

2800 ROMORA BAY DR
PITTSBURG CA
94565-7921
US

V. Phone/Fax

Practice location:
  • Phone: 209-573-6181
  • Fax:
Mailing address:
  • Phone: 925-705-0203
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: