Healthcare Provider Details

I. General information

NPI: 1992235105
Provider Name (Legal Business Name): VIDYA MAHAVADI MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/20/2017
Last Update Date: 11/25/2024
Certification Date: 11/25/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9300 VALLEY CHILDRENS PL # SC63
MADERA CA
93636-8761
US

IV. Provider business mailing address

9300 VALLEY CHILDRENS PL # SC05
MADERA CA
93636-8761
US

V. Phone/Fax

Practice location:
  • Phone: 559-353-5542
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number125-071062
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberA188414
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: