Healthcare Provider Details

I. General information

NPI: 1659200616
Provider Name (Legal Business Name): MODAX CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/15/2026
Last Update Date: 05/15/2026
Certification Date: 05/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6439 MARYMOUNT ST
CHINO CA
91710-1110
US

IV. Provider business mailing address

6439 MARYMOUNT ST
CHINO CA
91710-1110
US

V. Phone/Fax

Practice location:
  • Phone: 909-455-3794
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: MR. MOHAMMAD M SIDDIQUI
Title or Position: MEDICAL DIRECTOR
Credential: MD
Phone: 909-455-3794