Healthcare Provider Details

I. General information

NPI: 1487090049
Provider Name (Legal Business Name): JESUA ISRAEL LAW D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/21/2013
Last Update Date: 07/27/2020
Certification Date: 07/27/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

609 E ORANGEBURG AVE STE 201
MODESTO CA
95350-5512
US

IV. Provider business mailing address

609 E ORANGEBURG AVE STE 201
MODESTO CA
95350-5512
US

V. Phone/Fax

Practice location:
  • Phone: 209-572-3224
  • Fax:
Mailing address:
  • Phone: 209-572-3224
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number10796316-1204
License Number StateUT
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License NumberG083433500
License Number StateOK
# 3
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number20A13918
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: