Provider Demographics
NPI:1770002339
Name:MADONICK, JOSHUA (PT, DPT, CSCS)
Entity Type:Individual
Prefix:
First Name:JOSHUA
Middle Name:
Last Name:MADONICK
Suffix:
Gender:M
Credentials:PT, DPT, CSCS
Other - Prefix:
Other - First Name:JOSH
Other - Middle Name:
Other - Last Name:MADONICK
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PT, DPT, CSCS
Mailing Address - Street 1:86 EUCALYPTUS RD
Mailing Address - Street 2:
Mailing Address - City:PETALUMA
Mailing Address - State:CA
Mailing Address - Zip Code:94952-1654
Mailing Address - Country:US
Mailing Address - Phone:925-918-0470
Mailing Address - Fax:
Practice Address - Street 1:1320 INDUSTRIAL AVE STE K
Practice Address - Street 2:
Practice Address - City:PETALUMA
Practice Address - State:CA
Practice Address - Zip Code:94952-6522
Practice Address - Country:US
Practice Address - Phone:925-918-0470
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-09-14
Last Update Date:2020-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
2251X0800X
CA293676225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic