Provider Demographics
NPI:1629440508
Name:ELAINE M. MADAYAG MD, A PROFESSIONAL CORPORATION
Entity Type:Organization
Organization Name:ELAINE M. MADAYAG MD, A PROFESSIONAL CORPORATION
Other - Org Name:ELAINE MADAYAG-CAPUNO, M.D.
Other - Org Type:Other Name
Authorized Official - Title/Position:OWNER/DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:ELAINE
Authorized Official - Middle Name:M
Authorized Official - Last Name:MADAYAGCAPUNO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:209-847-2920
Mailing Address - Street 1:PO BOX 1946
Mailing Address - Street 2:
Mailing Address - City:OAKDALE
Mailing Address - State:CA
Mailing Address - Zip Code:95361-1946
Mailing Address - Country:US
Mailing Address - Phone:209-847-2920
Mailing Address - Fax:209-847-2892
Practice Address - Street 1:715 W F ST
Practice Address - Street 2:
Practice Address - City:OAKDALE
Practice Address - State:CA
Practice Address - Zip Code:95361-3736
Practice Address - Country:US
Practice Address - Phone:209-847-2920
Practice Address - Fax:209-847-2892
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-10-30
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA63167207R00000X, 261QM2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
No261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical SpecialtyGroup - Single Specialty