Healthcare Provider Details

I. General information

NPI: 1578940045
Provider Name (Legal Business Name): EVERETT JAMES MODING MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/04/2015
Last Update Date: 07/21/2020
Certification Date: 07/21/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 PASTEUR DR
STANFORD CA
94305-2200
US

IV. Provider business mailing address

300 PASTEUR DR
STANFORD CA
94305-2200
US

V. Phone/Fax

Practice location:
  • Phone: 336-832-7272
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number209574
License Number StateNC
# 2
Primary TaxonomyY
Taxonomy Code2085R0001X
TaxonomyRadiation Oncology Physician
License NumberA143827
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: