Healthcare Provider Details

I. General information

NPI: 1659697092
Provider Name (Legal Business Name): PARDEEP ATHWAL M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/09/2010
Last Update Date: 11/06/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

768 MOUNTAIN RANCH RD
SAN ANDREAS CA
95249-9707
US

IV. Provider business mailing address

450 GLASS LN STE C
MODESTO CA
95356-9287
US

V. Phone/Fax

Practice location:
  • Phone: 209-754-2573
  • Fax:
Mailing address:
  • Phone: 209-342-2300
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number144278
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: