Provider Demographics
NPI:1457982001
Name:ISAGUIRRE, MODESTY JOY (LE)
Entity Type:Individual
Prefix:
First Name:MODESTY
Middle Name:JOY
Last Name:ISAGUIRRE
Suffix:
Gender:F
Credentials:LE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:824 N PASADENA AVE APT 14
Mailing Address - Street 2:
Mailing Address - City:AZUSA
Mailing Address - State:CA
Mailing Address - Zip Code:91702-2573
Mailing Address - Country:US
Mailing Address - Phone:909-954-8363
Mailing Address - Fax:
Practice Address - Street 1:140 S GRAND AVE
Practice Address - Street 2:
Practice Address - City:GLENDORA
Practice Address - State:CA
Practice Address - Zip Code:91741-4259
Practice Address - Country:US
Practice Address - Phone:213-973-3278
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-02-03
Last Update Date:2020-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAL9653207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty