Healthcare Provider Details

I. General information

NPI: 1982862926
Provider Name (Legal Business Name): ICHCHHA MADAN M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/27/2008
Last Update Date: 08/10/2021
Certification Date: 07/15/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4940 EASTERN AVE # A121
BALTIMORE MD
21224-2735
US

IV. Provider business mailing address

6201 GREENLEIGH AVE
BALTIMORE MD
21220-2004
US

V. Phone/Fax

Practice location:
  • Phone: 410-550-0336
  • Fax: 410-550-0196
Mailing address:
  • Phone: 410-933-6423
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number4301091439
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License NumberD90730
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: