Provider Demographics
NPI:1679551352
Name:MODI, TUSHAR R (MD)
Entity type:Individual
Prefix:DR
First Name:TUSHAR
Middle Name:R
Last Name:MODI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:413 E ORANGEBURG AVE
Mailing Address - Street 2:SUITE A
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95350-5315
Mailing Address - Country:US
Mailing Address - Phone:209-529-9600
Mailing Address - Fax:209-544-2620
Practice Address - Street 1:413 E ORANGEBURG AVE
Practice Address - Street 2:SUITE A
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95350-5315
Practice Address - Country:US
Practice Address - Phone:209-529-9600
Practice Address - Fax:209-544-2620
Is Sole Proprietor?:No
Enumeration Date:2006-01-04
Last Update Date:2010-02-19
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAA44738207RG0300X
CAA447380207RS0010X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine
No207RS0010XAllopathic & Osteopathic PhysiciansInternal MedicineSports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A447380Medicare ID - Type Unspecified