Healthcare Provider Details

I. General information

NPI: 1467508259
Provider Name (Legal Business Name): JOHN MICHAEL MADONNA JR. EDD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/26/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

469 CHANDLER STREET
WORCESTER MA
01602
US

IV. Provider business mailing address

469 CHANDLER STREET
WORCESTER MA
01602
US

V. Phone/Fax

Practice location:
  • Phone: 508-757-7430
  • Fax: 508-791-5845
Mailing address:
  • Phone: 508-757-7430
  • Fax: 508-791-5845

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number2711
License Number StateMA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
IdentifierW02886
Identifier TypeOTHER
Identifier StateMA
Identifier IssuerBCBS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: