Provider Demographics
NPI:1639244999
Name:SANJAY K MADAN MD PA
Entity Type:Organization
Organization Name:SANJAY K MADAN MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SANJAY
Authorized Official - Middle Name:K
Authorized Official - Last Name:MADAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:727-669-2969
Mailing Address - Street 1:3190 MCMULLEN BOOTH RD
Mailing Address - Street 2:STE 201
Mailing Address - City:CLEARWATER
Mailing Address - State:FL
Mailing Address - Zip Code:33761
Mailing Address - Country:US
Mailing Address - Phone:727-669-2969
Mailing Address - Fax:727-669-7460
Practice Address - Street 1:3190 MCMULLEN BOOTH RD
Practice Address - Street 2:STE 201
Practice Address - City:CLEARWATER
Practice Address - State:FL
Practice Address - Zip Code:33761
Practice Address - Country:US
Practice Address - Phone:727-669-2969
Practice Address - Fax:727-669-7460
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-22
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0073402207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL34721OtherBC
G46689Medicare UPIN
FL34721OtherBC