Healthcare Provider Details

I. General information

NPI: 1639090061
Provider Name (Legal Business Name): MARQUE D MODICA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/22/2026
Last Update Date: 07/22/2026
Certification Date: 07/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4342 BLAKE CIR
STOCKTON CA
95206-6515
US

IV. Provider business mailing address

4134 GISELLE LN
STOCKTON CA
95206-6508
US

V. Phone/Fax

Practice location:
  • Phone: 925-766-6256
  • Fax:
Mailing address:
  • Phone: 925-766-6256
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225400000X
TaxonomyRehabilitation Practitioner
License Number
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: