Healthcare Provider Details

I. General information

NPI: 1962578583
Provider Name (Legal Business Name): GEORGE M MADANAT MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/27/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1330 W COVINA BLVD SUITE 106
SAN DIMAS CA
91773
US

IV. Provider business mailing address

1330 W COVINA BLVD SUITE 106
SAN DIMAS CA
91773
US

V. Phone/Fax

Practice location:
  • Phone: 909-599-6876
  • Fax: 909-592-9787
Mailing address:
  • Phone: 909-599-6876
  • Fax: 909-592-9787

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberA26511
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: