Provider Demographics
NPI:1023754843
Name:MADAN, MIHAIL
Entity type:Individual
Prefix:
First Name:MIHAIL
Middle Name:
Last Name:MADAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22106 43RD AVE W
Mailing Address - Street 2:
Mailing Address - City:MOUNTLAKE TERRACE
Mailing Address - State:WA
Mailing Address - Zip Code:98043-3611
Mailing Address - Country:US
Mailing Address - Phone:206-430-3889
Mailing Address - Fax:
Practice Address - Street 1:22106 43RD AVE W
Practice Address - Street 2:
Practice Address - City:MOUNTLAKE TERRACE
Practice Address - State:WA
Practice Address - Zip Code:98043-3611
Practice Address - Country:US
Practice Address - Phone:206-430-3889
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-05-05
Last Update Date:2022-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAA755204311ZA0620X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes311ZA0620XNursing & Custodial Care FacilitiesCustodial Care FacilityAdult Care Home
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2195411Medicaid