Provider Demographics
NPI:1871357962
Name:MOFOR, NADESH A
Entity type:Individual
Prefix:
First Name:NADESH
Middle Name:A
Last Name:MOFOR
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7707 AUSTIN RD
Mailing Address - Street 2:
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95215-8312
Mailing Address - Country:US
Mailing Address - Phone:209-467-3553
Mailing Address - Fax:
Practice Address - Street 1:7707 AUSTIN RD
Practice Address - Street 2:
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95215-8312
Practice Address - Country:US
Practice Address - Phone:209-467-3553
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-02-08
Last Update Date:2024-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA120948390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program