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General NPI Number Information
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NPI Number | 1235364258
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Entity Type | Individual
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Provider Name | MARY JESSIE SUMITHRA M.D
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Gender | Female
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Dates
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Enumeration Date | 05/19/2009
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Last Update Date | 12/13/2021
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Provider Practice Location Address
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Address Line | 4125 BANGS AVE
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City | MODESTO
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State | CA
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Zip | 95356-8713
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Country | US
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Telephone | 209-557-1630
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Fax |
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Provider Business Mailing Address
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Address Line | 501 6TH ST APT 12-J
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City | BROOKLYN
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State | NY
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Zip | 11215-3671
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208000000X
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Taxonomy Name | Pediatrics Physician
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License Number | A105261
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License Number State | CA
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