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General NPI Number Information
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NPI Number | 1669633376
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Entity Type | Individual
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Provider Name | LADAN MODALLEL MD
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Gender | Female
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Dates
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Enumeration Date | 06/24/2008
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Last Update Date | 08/18/2025
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Provider Practice Location Address
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Address Line | 1574 W BASE LINE ST STE 107
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City | SAN BERNARDINO
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State | CA
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Zip | 92411-1736
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Country | US
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Telephone | 909-386-1880
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Fax | 909-386-1882
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Provider Business Mailing Address
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Address Line | 742 W HIGHLAND AVE
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City | SAN BERNARDINO
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State | CA
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Zip | 92405-3839
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Country | US
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Telephone | 909-386-1880
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Fax | 909-386-1882
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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 | 44915
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License Number State | KY
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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 | MD60914735
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License Number State | WA
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Taxonomy #3
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Taxonomy Code | 208000000X
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Taxonomy Name | Pediatrics Physician
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License Number | 117285
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License Number State | CA
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