Provider Demographics
NPI:1992867204
Name:MADANI, MAYURA S (MD)
Entity Type:Individual
Prefix:DR
First Name:MAYURA
Middle Name:S
Last Name:MADANI
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4160 JOHN R STREET
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48201-1303
Mailing Address - Country:US
Mailing Address - Phone:248-709-6596
Mailing Address - Fax:313-833-4648
Practice Address - Street 1:4160 JOHN R STREET
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48201
Practice Address - Country:US
Practice Address - Phone:313-833-4629
Practice Address - Fax:313-833-4648
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-14
Last Update Date:2019-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301062772208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI104788033Medicaid
MI104788033Medicaid