=====================================================
General NPI Number Information
=====================================================
NPI Number | 1235379207
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | BRIAN DAVID MODENA M.D., MSC
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/03/2009
-----------------------------------------------------
Last Update Date | 04/09/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 9850 GENESEE AVE STE 710
-----------------------------------------------------
City | LA JOLLA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92037-1218
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 858-260-2977
-----------------------------------------------------
Fax | 858-260-2978
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 9850 GENESEE AVE STE 710
-----------------------------------------------------
City | LA JOLLA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92037-1218
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 858-260-2977
-----------------------------------------------------
Fax | 858-260-2978
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207R00000X
-----------------------------------------------------
Taxonomy Name | Internal Medicine Physician
-----------------------------------------------------
License Number | A103242
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207RA0201X
-----------------------------------------------------
Taxonomy Name | Allergy & Immunology (Internal Medicine) Physician
-----------------------------------------------------
License Number | A103242
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 207K00000X
-----------------------------------------------------
Taxonomy Name | Allergy & Immunology Physician
-----------------------------------------------------
License Number | A103242
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------