Healthcare Provider Details

I. General information

NPI: 1629440508
Provider Name (Legal Business Name): ELAINE M. MADAYAG MD, A PROFESSIONAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/30/2015
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

715 W F ST
OAKDALE CA
95361-3736
US

IV. Provider business mailing address

PO BOX 1946
OAKDALE CA
95361-1946
US

V. Phone/Fax

Practice location:
  • Phone: 209-847-2920
  • Fax: 209-847-2892
Mailing address:
  • Phone: 209-847-2920
  • Fax: 209-847-2892

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberA63167
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code261QM2500X
TaxonomyMedical Specialty Clinic/Center
License NumberA63167
License Number StateCA

VIII. Authorized Official

Name: DR. ELAINE M MADAYAGCAPUNO
Title or Position: OWNER/DIRECTOR
Credential: MD
Phone: 209-847-2920