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General NPI Number Information
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NPI Number | 1366547796
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Entity Type | Organization
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Legal Business Name | MODESTO PEDIATRICS
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Dates
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Enumeration Date | 09/13/2006
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Last Update Date | 08/16/2011
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Provider Practice Location Address
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Address Line | 3109 COFFEE RD STE A
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City | MODESTO
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State | CA
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Zip | 95355-1766
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Country | US
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Telephone | 209-522-0001
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Fax | 209-549-7077
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Provider Business Mailing Address
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Address Line | PO BOX 578202
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City | MODESTO
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State | CA
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Zip | 95357-8202
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Country | US
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Telephone | 209-522-0001
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Fax | 209-549-7077
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Authorized Official
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Title or Position | PRESIDENT
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Name | ANN MARIE TRUSCELLO
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Credential | MD
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Telephone | 209-522-0001
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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 | G83542
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License Number State | CA
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Taxonomy #2
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Taxonomy Code | 208000000X
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Taxonomy Name | Pediatrics Physician
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License Number | G68634
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License Number State | CA
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