Provider Demographics
NPI:1760601769
Name:SUMITRA, LEENA M
Entity Type:Individual
Prefix:
First Name:LEENA
Middle Name:M
Last Name:SUMITRA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1320 STANDIFORD AVE STE 5
Mailing Address - Street 2:
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95350-0726
Mailing Address - Country:US
Mailing Address - Phone:209-557-1000
Mailing Address - Fax:
Practice Address - Street 1:4125 BANGS AVE
Practice Address - Street 2:
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95356-8713
Practice Address - Country:US
Practice Address - Phone:209-557-1000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-25
Last Update Date:2016-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA978942084P0800X
WAMD604396482084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry