Provider Demographics
NPI:1770929986
Name:PRITI MODI, M.D. INC.
Entity type:Organization
Organization Name:PRITI MODI, M.D. INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:PRITI
Authorized Official - Middle Name:T
Authorized Official - Last Name:MODI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:209-409-8589
Mailing Address - Street 1:1608 TULLY RD
Mailing Address - Street 2:
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95350-4031
Mailing Address - Country:US
Mailing Address - Phone:209-409-8589
Mailing Address - Fax:209-409-8691
Practice Address - Street 1:1608 TULLY RD
Practice Address - Street 2:
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95350-4031
Practice Address - Country:US
Practice Address - Phone:209-409-8589
Practice Address - Fax:209-409-8691
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-05-14
Last Update Date:2014-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA52036207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1568440246-01Medicaid
CAF96685OtherMEDICARE PTAN
CA00A520360Medicare PIN