Provider Demographics
NPI:1710103023
Name:MADANTSCHI, MOHAMMAD (MD)
Entity Type:Individual
Prefix:DR
First Name:MOHAMMAD
Middle Name:
Last Name:MADANTSCHI
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 1:5761 W PINNACLE HILL DR
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85310-3632
Mailing Address - Country:US
Mailing Address - Phone:623-734-5808
Mailing Address - Fax:
Practice Address - Street 1:9305 W THOMAS RD STE 485
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85037
Practice Address - Country:US
Practice Address - Phone:623-815-7800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-17
Last Update Date:2019-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ37565207R00000X, 207RP1001X, 207RS0012X
GUM001359207RC0200X, 207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RS0012XAllopathic & Osteopathic PhysiciansInternal MedicineSleep Medicine
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
No207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
H39129Medicare UPIN
H53495Medicare ID - Type Unspecified