Healthcare Provider Details

I. General information

NPI: 1841499563
Provider Name (Legal Business Name): MICHAEL G MADANAT M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/12/2007
Last Update Date: 06/30/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1330 W COVINA BLVD SUITE 106
SAN DIMAS CA
91773-3200
US

IV. Provider business mailing address

1330 W COVINA BLVD SUITE 106
SAN DIMAS CA
91773-3200
US

V. Phone/Fax

Practice location:
  • Phone: 626-963-7675
  • Fax:
Mailing address:
  • Phone: 626-963-7675
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberA106499
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: