Provider Demographics
NPI:1265650493
Name:MADATOVIAN, VAHAN (MD)
Entity type:Individual
Prefix:
First Name:VAHAN
Middle Name:
Last Name:MADATOVIAN
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 1:501 W GLENOAKS BLVD
Mailing Address - Street 2:SUITE 205
Mailing Address - City:GLENDALE
Mailing Address - State:CA
Mailing Address - Zip Code:91202-4042
Mailing Address - Country:US
Mailing Address - Phone:818-549-9630
Mailing Address - Fax:818-549-9631
Practice Address - Street 1:501 W GLENOAKS BLVD
Practice Address - Street 2:SUITE 205
Practice Address - City:GLENDALE
Practice Address - State:CA
Practice Address - Zip Code:91202-4042
Practice Address - Country:US
Practice Address - Phone:818-549-9630
Practice Address - Fax:818-549-9631
Is Sole Proprietor?:No
Enumeration Date:2007-04-23
Last Update Date:2010-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA53748207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A537480Medicaid
F93623Medicare UPIN
CAA53748Medicare ID - Type Unspecified