Healthcare Provider Details

I. General information

NPI: 1700210762
Provider Name (Legal Business Name): KANAN MODI MD INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/27/2013
Last Update Date: 08/27/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1305 W ARROW HWY STE 104
SAN DIMAS CA
91773-2337
US

IV. Provider business mailing address

1305 W ARROW HWY STE 104
SAN DIMAS CA
91773-2337
US

V. Phone/Fax

Practice location:
  • Phone: 909-394-9004
  • Fax: 909-394-9461
Mailing address:
  • Phone: 909-394-9004
  • Fax: 909-394-9461

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number StateCA

VIII. Authorized Official

Name: KANAN MODI
Title or Position: OWNER
Credential: MD
Phone: 909-394-9004