Healthcare Provider Details

I. General information

NPI: 1194942078
Provider Name (Legal Business Name): IAN MADOM MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/20/2007
Last Update Date: 05/22/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 HIGH ST
WAKEFIELD RI
02879
US

IV. Provider business mailing address

1 HIGH ST
WAKEFIELD RI
02879-3103
US

V. Phone/Fax

Practice location:
  • Phone: 401-789-1422
  • Fax: 401-782-6810
Mailing address:
  • Phone: 401-789-1422
  • Fax: 401-782-6810

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207XS0117X
TaxonomyOrthopaedic Surgery of the Spine Physician
License Number256162
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code207XX0801X
TaxonomyOrthopaedic Trauma Physician
License Number256162
License Number StateNY
# 3
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License NumberMD12744
License Number StateRI
# 4
Primary TaxonomyN
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License NumberLP00165
License Number StateRI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: