Provider Demographics
NPI:1043353667
Name:MODHWADIA, MAMTA DEVSHI (MD)
Entity Type:Individual
Prefix:DR
First Name:MAMTA
Middle Name:DEVSHI
Last Name:MODHWADIA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:3853 ROSECRANS STREET
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92110-3960
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3853 ROSECRANS STREET
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92110-3960
Practice Address - Country:US
Practice Address - Phone:619-692-8232
Practice Address - Fax:619-542-4060
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-14
Last Update Date:2014-06-12
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAA1139902084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry