Individual
DIVYA PANNALA
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
M.D.
Contact information
Practice address
3612 DALE RD, MODESTO, CA 95356-0500
(209) 522-0146
Mailing address
600 COFFEE RD, MODESTO, CA 95355-4201
(209) 521-6097
Taxonomy
Speciality
Code
Description
License number
State
207Q00000X
Family Medicine Physician
Primary
A116350
CA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
MT-193188
LICENSE
PA
Enumeration date
05/08/2009
Last updated
11/26/2012
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