=====================================================
General NPI Number Information
=====================================================
NPI Number | 1104986165
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | VINITA WADHWANI MD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/11/2006
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1400 CELESTE DRIVE CRESTWOOD MANNOR
-----------------------------------------------------
City | MODESTO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95355
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 916-422-5856
-----------------------------------------------------
Fax | 916-422-2307
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 700 STILL BREEZE WAY
-----------------------------------------------------
City | SACRAMENTO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95831
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 916-427-8161
-----------------------------------------------------
Fax | 916-422-2307
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2084P0800X
-----------------------------------------------------
Taxonomy Name | Psychiatry Physician
-----------------------------------------------------
License Number | 00A320720
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------