Provider Demographics
NPI:1366547796
Name:MODESTO PEDIATRICS
Entity type:Organization
Organization Name:MODESTO PEDIATRICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ANN
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:TRUSCELLO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:209-522-0001
Mailing Address - Street 1:PO BOX 578202
Mailing Address - Street 2:
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95357-8202
Mailing Address - Country:US
Mailing Address - Phone:209-522-0001
Mailing Address - Fax:209-549-7077
Practice Address - Street 1:3109 COFFEE RD
Practice Address - Street 2:STE A
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95355-1766
Practice Address - Country:US
Practice Address - Phone:209-522-0001
Practice Address - Fax:209-549-7077
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-13
Last Update Date:2011-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG83542208000000X
CAG68634208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0094690Medicaid
CAZZZ07358ZOtherBLUE SHIELD GROUP PIN