Jesse Russell Modica, P.T., D.P.T., M.S.

Primary specialty

Orthopedic Physical TherapistTaxonomy code 2251X0800X

License

33875 Issued in CA

Practice address

165 N Redwood Dr
Suite 120
San Rafael, CA 94903-1969

Phone

(415) 499-0278

NPI assigned

May 21, 2008

Reactivated

Apr 10, 2020

Last updated

Apr 10, 2020By the provider in NPPES

Sex

Male

Sole proprietor

No

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 1

Addresses

Medicare fee-for-service enrollment

Not listed in the public Medicare enrollment file

Medicare enrollment (NPD)

Not enrolled

Credentials

Master of Science

State licenses

Practice roles

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships, National Provider Directory roles and organizations whose NPPES authorized official is this provider.

• Marin Physical Therapy, Inc.

  • Specialist
  • San Rafael, CA
  • NPI 1275658148
  NPD (past)

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1211328000000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1586476800000",
    "number": "1700043221",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "165 N REDWOOD DR",
            "address_2": "SUITE 120",
            "city": "SAN RAFAEL",
            "state": "CA",
            "postal_code": "949031969",
            "telephone_number": "414-499-0278"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "165 N REDWOOD DR",
            "address_2": "SUITE 120",
            "city": "SAN RAFAEL",
            "state": "CA",
            "postal_code": "949031969",
            "telephone_number": "415-499-0278"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "MODICA",
        "first_name": "JESSE",
        "middle_name": "RUSSELL",
        "name_prefix": "Dr.",
        "credential": "P.T., D.P.T., M.S.",
        "sole_proprietor": "NO",
        "sex": "M",
        "enumeration_date": "2008-05-21",
        "last_updated": "2020-04-10",
        "certification_date": "2020-04-10",
        "deactivation_date": "2019-08-07",
        "reactivation_date": "2020-04-10",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "2251X0800X",
            "taxonomy_group": "",
            "desc": "Physical Therapist, Orthopedic",
            "state": "CA",
            "license": "33875",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

• Gary S. Mizono, MD
• Stephen G. Mizroch, MD
• Anita Shieh Mo, PHARM.D.
• Mobility Masters of Marin
• Mary B. Mockus, MD
• Tanaz Mohammadi, O.D.
• Sarah Huxtable Mohr
• Sheila Sahar Moin, PA-C
• Mona Mokri
• Carlos Molina, ED.D., MFT

• Orthopedic Physical Therapist in San Rafael, CA
• Providers in San Rafael, CA by specialty
• Orthopedic Physical Therapist in California

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Apr 10, 2020; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.