Healthcare Provider Details

I. General information

NPI: 1336247121
Provider Name (Legal Business Name): ELIO MADAN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/20/2006
Last Update Date: 09/09/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

132 E MADISON ST
STARKE FL
32091-4043
US

IV. Provider business mailing address

1634 COLONIAL DR
GREEN COVE SPRINGS FL
32043
US

V. Phone/Fax

Practice location:
  • Phone: 904-964-6500
  • Fax: 904-964-9170
Mailing address:
  • Phone: 904-284-4715
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License NumberME61095
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: