MEDICARE: ANDY MADOYAN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	247ZC0005X	Clinical Laboratory Director (Non-physician)	05D2145028	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	C6236693	OTHER	CA	DRIVERS LICENSE

General Provider Information

NPI Number	:	1811492028
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ANDY MADOYAN

Provider Business Mailing Address
First Line	:	1737 E WASHINGTON BLVD STE 5
Second Line	:
City	:	PASADENA
State	:	CA
Zip	:	91104-2772
Country	:	US
Telephone Number	:	626-314-2222
Fax Number	:	626-314-2224

Provider Business Practice Location Address
First Line	:	1737 E WASHINGTON BLVD STE 5
Second Line	:
City	:	PASADENA
State	:	CA
Zip	:	91104-2772
Country	:	US
Telephone Number	:	626-314-2222
Fax Number	:	626-314-2224

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/28/2018
Last Update Date	:	03/28/2018

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Directions to “ ANDY MADOYAN ” Practice Location

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