Provider Demographics
NPI:1013988229
Name:MIODOVNIK, MENACHEM (MD)
Entity Type:Individual
Prefix:DR
First Name:MENACHEM
Middle Name:
Last Name:MIODOVNIK
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 1:4611 CHARLESTON TER NW
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20007-1912
Mailing Address - Country:US
Mailing Address - Phone:646-337-7777
Mailing Address - Fax:
Practice Address - Street 1:110 IRVING ST NW
Practice Address - Street 2:DEPT. OF OB/GYN
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20010-2976
Practice Address - Country:US
Practice Address - Phone:202-877-9663
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-27
Last Update Date:2011-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCMD034456207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
DC010082587Medicaid
DC405009600Medicaid
DC035718900Medicaid
DC010082587Medicaid
DC405009600Medicaid
DC014522W25Medicare ID - Type UnspecifiedTRAILBLAZER