Provider Demographics
NPI:1982611760
Name:MADANI, MIR M (MD)
Entity Type:Individual
Prefix:
First Name:MIR
Middle Name:M
Last Name:MADANI
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:PO BOX 827
Mailing Address - Street 2:
Mailing Address - City:LOS ALAMITOS
Mailing Address - State:CA
Mailing Address - Zip Code:90720-0827
Mailing Address - Country:US
Mailing Address - Phone:562-598-2141
Mailing Address - Fax:
Practice Address - Street 1:3801 KATELLA AVE
Practice Address - Street 2:STE 310
Practice Address - City:LOS ALAMITOS
Practice Address - State:CA
Practice Address - Zip Code:90720-3338
Practice Address - Country:US
Practice Address - Phone:562-598-2141
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-02
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA66572207RC0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
G58255Medicare UPIN