Provider Demographics
NPI:1881748846
Name:MODESTO GASTROENTEROLOGY MEDICAL CORPORATION
Entity type:Organization
Organization Name:MODESTO GASTROENTEROLOGY MEDICAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ELSAKR
Authorized Official - Middle Name:
Authorized Official - Last Name:MAGDY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:209-338-0292
Mailing Address - Street 1:2336 SYLVAN AVE
Mailing Address - Street 2:SUITE A
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95355-9211
Mailing Address - Country:US
Mailing Address - Phone:209-338-0292
Mailing Address - Fax:209-338-0298
Practice Address - Street 1:2336 SYLVAN AVE
Practice Address - Street 2:SUITE A
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95355-9211
Practice Address - Country:US
Practice Address - Phone:209-338-0292
Practice Address - Fax:209-338-0298
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-23
Last Update Date:2022-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA45724207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CADD2244OtherMEDICARE ID
CAZZZ28570ZMedicare PIN