Provider Demographics
NPI:1376514489
Name:MODI, MAHESH G (MD)
Entity Type:Individual
Prefix:MR
First Name:MAHESH
Middle Name:G
Last Name:MODI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:PO BOX 986
Mailing Address - Street 2:
Mailing Address - City:WOODBRIDGE
Mailing Address - State:CA
Mailing Address - Zip Code:95258-0986
Mailing Address - Country:US
Mailing Address - Phone:209-339-9036
Mailing Address - Fax:209-339-1901
Practice Address - Street 1:2160 W GRANT LINE RD
Practice Address - Street 2:SUITE 240
Practice Address - City:TRACY
Practice Address - State:CA
Practice Address - Zip Code:95377-7330
Practice Address - Country:US
Practice Address - Phone:209-833-6118
Practice Address - Fax:209-835-7999
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-27
Last Update Date:2010-01-20
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
CAA37333207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A373330Medicaid
CA00A373330Medicare PIN
CA00A373330Medicaid