Healthcare Provider Details

I. General information

NPI: 1205973708
Provider Name (Legal Business Name): BADROSSADAT MADANI M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/31/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14701 179TH AVE SE
MONROE WA
98272-1108
US

IV. Provider business mailing address

14701 179TH AVE SE
MONROE WA
98272-1108
US

V. Phone/Fax

Practice location:
  • Phone: 360-863-4664
  • Fax: 360-860-4663
Mailing address:
  • Phone: 360-863-4664
  • Fax: 360-860-4663

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080A0000X
TaxonomyPediatric Adolescent Medicine Physician
License NumberMD00030585
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: