Healthcare Provider Details

I. General information

NPI: 1992170542
Provider Name (Legal Business Name): MODESTO RADIOLOGICAL MEDICAL GROUP, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/08/2015
Last Update Date: 10/04/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

728 MURPHY DR
SAN MATEO CA
94402-3421
US

IV. Provider business mailing address

1524 MCHENRY AVE SUITE 430
MODESTO CA
95350-4500
US

V. Phone/Fax

Practice location:
  • Phone: 599-455-4009
  • Fax: 916-533-0313
Mailing address:
  • Phone: 559-455-4009
  • Fax: 916-533-0023

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number
License Number State

VIII. Authorized Official

Name: MARK MOORE
Title or Position: CFO
Credential:
Phone: 209-342-5946