Provider Demographics
NPI:1760466700
Name:MADISON PARK FAMILY MEDICAL
Entity Type:Organization
Organization Name:MADISON PARK FAMILY MEDICAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DO
Authorized Official - Prefix:
Authorized Official - First Name:NEDA
Authorized Official - Middle Name:
Authorized Official - Last Name:BAYAT
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:310-944-9344
Mailing Address - Street 1:1970 SO PROSPECT AVE
Mailing Address - Street 2:SUITE 3
Mailing Address - City:REDONDO BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90277
Mailing Address - Country:US
Mailing Address - Phone:310-944-9344
Mailing Address - Fax:310-944-9390
Practice Address - Street 1:1970 SO PROSPECT AVE
Practice Address - Street 2:SUITE 3
Practice Address - City:REDONDO BEACH
Practice Address - State:CA
Practice Address - Zip Code:90277
Practice Address - Country:US
Practice Address - Phone:310-944-9344
Practice Address - Fax:310-944-9390
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-02
Last Update Date:2007-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A7340207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
W13994OtherGROUP MCARE
W13994OtherGROUP MCARE
W20A7340AMedicare ID - Type Unspecified