Provider Demographics
NPI:1568440246
Name:MODI, PRITI TUSHAR (MD, FACP)
Entity Type:Individual
Prefix:DR
First Name:PRITI
Middle Name:TUSHAR
Last Name:MODI
Suffix:
Gender:F
Credentials:MD, FACP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1608 TULLY RD
Mailing Address - Street 2:
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95350-4031
Mailing Address - Country:US
Mailing Address - Phone:209-409-8589
Mailing Address - Fax:209-409-8691
Practice Address - Street 1:1608 TULLY RD
Practice Address - Street 2:
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95350-4031
Practice Address - Country:US
Practice Address - Phone:209-409-8589
Practice Address - Fax:209-409-8691
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-04
Last Update Date:2016-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA52036207R00000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1568440246-01Medicaid
BA816OtherMEDICARE PTAN
CA1568440246-01Medicaid
CA1568440246-01Medicaid