Healthcare Provider Details

I. General information

NPI: 1922319573
Provider Name (Legal Business Name): PAVAN K MADAN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/29/2010
Last Update Date: 03/28/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1712 PICASSO AVE STE D
DAVIS CA
95618-0546
US

IV. Provider business mailing address

3835 N FREEWAY BLVD STE 100
SACRAMENTO CA
95834-1954
US

V. Phone/Fax

Practice location:
  • Phone: 530-297-7500
  • Fax: 530-297-7751
Mailing address:
  • Phone: 916-576-7900
  • Fax: 916-285-0338

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License Number134176
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number134176
License Number StateCA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: