Provider Demographics
NPI:1073799979
Name:MIR M. MADANI M.D. A PROFESSIONAL MEDICAL CORPORATION
Entity Type:Organization
Organization Name:MIR M. MADANI M.D. A PROFESSIONAL MEDICAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MIR
Authorized Official - Middle Name:M
Authorized Official - Last Name:MADANI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:562-598-2141
Mailing Address - Street 1:3801 KATELLA AVE
Mailing Address - Street 2:SUITE 310
Mailing Address - City:LOS ALAMITOS
Mailing Address - State:CA
Mailing Address - Zip Code:90720-3338
Mailing Address - Country:US
Mailing Address - Phone:562-598-2141
Mailing Address - Fax:562-598-1649
Practice Address - Street 1:3801 KATELLA AVE
Practice Address - Street 2:SUITE 310
Practice Address - City:LOS ALAMITOS
Practice Address - State:CA
Practice Address - Zip Code:90720-3338
Practice Address - Country:US
Practice Address - Phone:562-598-2141
Practice Address - Fax:562-598-1649
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-10
Last Update Date:2010-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAW18103Medicare PIN