Provider Demographics
NPI:1366461782
Name:MODERN NEUROCARE MEDICAL CENTER
Entity Type:Organization
Organization Name:MODERN NEUROCARE MEDICAL CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/CEO
Authorized Official - Prefix:
Authorized Official - First Name:MADAN
Authorized Official - Middle Name:
Authorized Official - Last Name:PRASAD
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:209-951-8830
Mailing Address - Street 1:PO BOX 7393
Mailing Address - Street 2:
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95267-0393
Mailing Address - Country:US
Mailing Address - Phone:209-951-8830
Mailing Address - Fax:209-951-8831
Practice Address - Street 1:1801 E MARCH LN
Practice Address - Street 2:SUITE B-220
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95210-6629
Practice Address - Country:US
Practice Address - Phone:209-951-8830
Practice Address - Fax:209-951-8831
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-18
Last Update Date:2018-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA866002084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A866000Medicaid
CAZZZ31728ZMedicare PIN