Provider Demographics
NPI:1013931088
Name:MADONNA, ROBERT C JR (DO)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:C
Last Name:MADONNA
Suffix:JR
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:ROBERT
Other - Middle Name:C
Other - Last Name:MADONNA
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DO
Mailing Address - Street 1:2504 GARRETT RD
Mailing Address - Street 2:
Mailing Address - City:DREXEL HILL
Mailing Address - State:PA
Mailing Address - Zip Code:19026-1011
Mailing Address - Country:US
Mailing Address - Phone:484-466-3007
Mailing Address - Fax:484-466-3042
Practice Address - Street 1:2504 GARRETT RD
Practice Address - Street 2:
Practice Address - City:DREXEL HILL
Practice Address - State:PA
Practice Address - Zip Code:19026-1011
Practice Address - Country:US
Practice Address - Phone:484-466-3007
Practice Address - Fax:474-466-3042
Is Sole Proprietor?:No
Enumeration Date:2006-07-26
Last Update Date:2012-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOS008317L207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA045149Medicare ID - Type Unspecified
PA232174959Medicare UPIN