Healthcare Provider Details

I. General information

NPI: 1265407993
Provider Name (Legal Business Name): VANDANA LAXMI MADHAVAN MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/17/2006
Last Update Date: 04/12/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

175 CAMBRIDGE ST CPZS-546, MASSGENERAL HOSPITAL FOR CHILDREN
BOSTON MA
02114-2743
US

IV. Provider business mailing address

175 CAMBRIDGE ST CPZS-546, MASSGENERAL HOSPITAL FOR CHILDREN
BOSTON MA
02114-2743
US

V. Phone/Fax

Practice location:
  • Phone: 617-643-0722
  • Fax: 617-643-0395
Mailing address:
  • Phone: 617-643-0722
  • Fax: 617-643-0395

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number223881
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: