Provider Demographics
NPI:1922199959
Name:ROSSINI, MICHAEL JR (MD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:
Last Name:ROSSINI
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1524 MCHENRY AVE
Mailing Address - Street 2:SUITE 515
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95350-4500
Mailing Address - Country:US
Mailing Address - Phone:209-491-5370
Mailing Address - Fax:209-491-5379
Practice Address - Street 1:1524 MCHENRY AVE
Practice Address - Street 2:SUITE 515
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95350
Practice Address - Country:US
Practice Address - Phone:209-491-5370
Practice Address - Fax:209-491-5379
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-27
Last Update Date:2012-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA45121174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A045121Medicaid
CA00A045121Medicare ID - Type Unspecified
CAD74420Medicare UPIN