Provider Demographics
NPI:1235379207
Name:MODENA, BRIAN DAVID (MD, MSC)
Entity Type:Individual
Prefix:DR
First Name:BRIAN
Middle Name:DAVID
Last Name:MODENA
Suffix:
Gender:M
Credentials:MD, MSC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9850 GENESEE AVE STE 710
Mailing Address - Street 2:
Mailing Address - City:LA JOLLA
Mailing Address - State:CA
Mailing Address - Zip Code:92037-1218
Mailing Address - Country:US
Mailing Address - Phone:858-260-2977
Mailing Address - Fax:858-260-2978
Practice Address - Street 1:9850 GENESEE AVE STE 710
Practice Address - Street 2:
Practice Address - City:LA JOLLA
Practice Address - State:CA
Practice Address - Zip Code:92037-1218
Practice Address - Country:US
Practice Address - Phone:858-260-2977
Practice Address - Fax:858-260-2978
Is Sole Proprietor?:No
Enumeration Date:2009-03-03
Last Update Date:2024-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA103242207R00000X, 207RA0201X, 207K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207K00000XAllopathic & Osteopathic PhysiciansAllergy & Immunology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RA0201XAllopathic & Osteopathic PhysiciansInternal MedicineAllergy & Immunology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO1235379207Medicaid
CAP00728773OtherRRM