Healthcare Provider Details

I. General information

NPI: 1285897272
Provider Name (Legal Business Name): PANKAJ MADAN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/09/2008
Last Update Date: 01/24/2023
Certification Date: 01/24/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

21727 IH 10 W STE 103
SAN ANTONIO TX
78257-2108
US

IV. Provider business mailing address

408 CLIFFSIDE DR
SHAVANO PARK TX
78231-1513
US

V. Phone/Fax

Practice location:
  • Phone: 210-644-1230
  • Fax: 210-702-4615
Mailing address:
  • Phone: 206-218-3652
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License NumberQ6873
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: