Healthcare Provider Details

I. General information

NPI: 1780953596
Provider Name (Legal Business Name): MADISON HEALTH CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/22/2011
Last Update Date: 05/11/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 CAPISTRANO DR
OAKLAND CA
94603-3520
US

IV. Provider business mailing address

1000 BROADWAY SUITE 500
OAKLAND CA
94607-4099
US

V. Phone/Fax

Practice location:
  • Phone: 510-636-4210
  • Fax:
Mailing address:
  • Phone: 510-267-8000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251K00000X
TaxonomyPublic Health or Welfare Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QC1500X
TaxonomyCommunity Health Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QS1000X
TaxonomyStudent Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. MUNTU R DAVIS
Title or Position: MEDICAL DIRECTOR
Credential: M.D.
Phone: 510-267-8010