Basic Information
| Provider Information | |||||||||
| NPI: | 1063831972 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MODIC | ||||||||
| FirstName: | ANDREW | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1081 N CHINA LAKE BLVD | ||||||||
| Address2: | |||||||||
| City: | RIDGECREST | ||||||||
| State: | CA | ||||||||
| PostalCode: | 935553130 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7604993855 | ||||||||
| FaxNumber: | 7604993870 | ||||||||
| Practice Location | |||||||||
| Address1: | 1111 N CHINA LAKE BLVD | ||||||||
| Address2: | |||||||||
| City: | RIDGECREST | ||||||||
| State: | CA | ||||||||
| PostalCode: | 935553131 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7604993855 | ||||||||
| FaxNumber: | 7604993870 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/08/2014 | ||||||||
| LastUpdateDate: | 02/12/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | MD.34762 | AL | N | Allopathic & Osteopathic Physicians | Internal Medicine | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 207R00000X | A155740 | CA | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
No ID Information.