Provider Demographics
NPI:1982696613
Name:MADIEVSKY, MICHAEL (MD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:MADIEVSKY
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 1:5525 ETIWANDA AVE STE 110
Mailing Address - Street 2:
Mailing Address - City:TARZANA
Mailing Address - State:CA
Mailing Address - Zip Code:91356-3642
Mailing Address - Country:US
Mailing Address - Phone:818-996-4796
Mailing Address - Fax:844-406-5413
Practice Address - Street 1:5525 ETIWANDA AVE STE 110
Practice Address - Street 2:
Practice Address - City:TARZANA
Practice Address - State:CA
Practice Address - Zip Code:91356-3642
Practice Address - Country:US
Practice Address - Phone:818-996-4796
Practice Address - Fax:844-406-5413
Is Sole Proprietor?:No
Enumeration Date:2005-08-18
Last Update Date:2020-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA65040207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A65040Medicaid
CAW18873Medicare ID - Type Unspecified
CA00A65040Medicaid
H29932Medicare UPIN