Provider Demographics
NPI:1265407993
Name:MADHAVAN, VANDANA LAXMI (MD)
Entity type:Individual
Prefix:DR
First Name:VANDANA
Middle Name:LAXMI
Last Name:MADHAVAN
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Gender:F
Credentials:MD
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Mailing Address - Street 1:175 CAMBRIDGE ST
Mailing Address - Street 2:CPZS-546, MASSGENERAL HOSPITAL FOR CHILDREN
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02114-2743
Mailing Address - Country:US
Mailing Address - Phone:617-643-0722
Mailing Address - Fax:617-643-0395
Practice Address - Street 1:175 CAMBRIDGE ST
Practice Address - Street 2:CPZS-546, MASSGENERAL HOSPITAL FOR CHILDREN
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02114-2743
Practice Address - Country:US
Practice Address - Phone:617-643-0722
Practice Address - Fax:617-643-0395
Is Sole Proprietor?:No
Enumeration Date:2006-02-17
Last Update Date:2013-04-12
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Provider Licenses
StateLicense IDTaxonomies
MA223881208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA2103214Medicaid
MAJ28679OtherBCBS MA
MA468282OtherTUFTS HEALTH PLAN
I32557Medicare UPIN
MA468282OtherTUFTS HEALTH PLAN