Provider Demographics
NPI:1336300052
Name:MADANI, REZA (MD)
Entity Type:Individual
Prefix:DR
First Name:REZA
Middle Name:
Last Name:MADANI
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 1:2001 HAMILTON ST
Mailing Address - Street 2:APT E5
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19130-4201
Mailing Address - Country:US
Mailing Address - Phone:215-219-8451
Mailing Address - Fax:
Practice Address - Street 1:1740 SOUTH ST
Practice Address - Street 2:SUITE 301
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19146-1514
Practice Address - Country:US
Practice Address - Phone:215-735-5600
Practice Address - Fax:215-735-5690
Is Sole Proprietor?:No
Enumeration Date:2008-06-25
Last Update Date:2011-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMT192992208000000X
PAMD442322208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics