Healthcare Provider Details

I. General information

NPI: 1336300052
Provider Name (Legal Business Name): REZA MADANI M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/25/2008
Last Update Date: 07/06/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1740 SOUTH ST SUITE 301
PHILADELPHIA PA
19146-1514
US

IV. Provider business mailing address

2001 HAMILTON ST APT E5
PHILADELPHIA PA
19130-4201
US

V. Phone/Fax

Practice location:
  • Phone: 215-735-5600
  • Fax: 215-735-5690
Mailing address:
  • Phone: 215-219-8451
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberMT192992
License Number StatePA
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberMD442322
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: