Provider Demographics
NPI:1194403048
Name:MODERSBACH, DAVID WILLIAM
Entity type:Individual
Prefix:
First Name:DAVID
Middle Name:WILLIAM
Last Name:MODERSBACH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2265 COURTLAND AVE
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94601-4707
Mailing Address - Country:US
Mailing Address - Phone:510-535-9122
Mailing Address - Fax:
Practice Address - Street 1:1404 FRANKLIN ST STE 200
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94612-3208
Practice Address - Country:US
Practice Address - Phone:510-891-8916
Practice Address - Fax:510-273-3802
Is Sole Proprietor?:Yes
Enumeration Date:2023-07-10
Last Update Date:2024-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA04011994172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes172V00000XOther Service ProvidersCommunity Health WorkerGroup - Single Specialty