Provider Demographics
NPI:1841499563
Name:MADANAT, MICHAEL G (MD)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:G
Last Name:MADANAT
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1330 W COVINA BLVD
Mailing Address - Street 2:SUITE 106
Mailing Address - City:SAN DIMAS
Mailing Address - State:CA
Mailing Address - Zip Code:91773-3200
Mailing Address - Country:US
Mailing Address - Phone:626-963-7675
Mailing Address - Fax:
Practice Address - Street 1:1330 W COVINA BLVD
Practice Address - Street 2:SUITE 106
Practice Address - City:SAN DIMAS
Practice Address - State:CA
Practice Address - Zip Code:91773-3200
Practice Address - Country:US
Practice Address - Phone:626-963-7675
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-12
Last Update Date:2010-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA106499208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics