Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207KA0200X | Allergist | 61142 | CO |
NPI | 1235379207 |
---|---|
Provider Name | Dr. Brian David Modena |
First Address | La Jolla, CA 92037-1212 |
Second Address | La Jolla, CA 92037-1212 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 03/03/2009 |
Last Update Date | 10/06/2021 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
1235379207 | (05) | CO |