Provider Demographics
NPI:1881704898
Name:MODI, KANAN (MD)
Entity type:Individual
Prefix:DR
First Name:KANAN
Middle Name:
Last Name:MODI
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1305 W ARROW HWY
Mailing Address - Street 2:104
Mailing Address - City:SAN DIMAS
Mailing Address - State:CA
Mailing Address - Zip Code:91773-2336
Mailing Address - Country:US
Mailing Address - Phone:909-394-9004
Mailing Address - Fax:909-394-9461
Practice Address - Street 1:1305 W ARROW HWY STE 104
Practice Address - Street 2:
Practice Address - City:SAN DIMAS
Practice Address - State:CA
Practice Address - Zip Code:91773-2337
Practice Address - Country:US
Practice Address - Phone:909-967-7826
Practice Address - Fax:909-394-9461
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-30
Last Update Date:2024-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA38793174400000X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A387930Medicaid
CAA38793OtherSTATE LICENSE