Provider Demographics
NPI:1447247473
Name:VANGA, MADHU SR
Entity type:Individual
Prefix:MR
First Name:MADHU
Middle Name:SR
Last Name:VANGA
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 1:1912 FAXON DRIVE
Mailing Address - Street 2:
Mailing Address - City:ATWATER
Mailing Address - State:CA
Mailing Address - Zip Code:95301
Mailing Address - Country:US
Mailing Address - Phone:209-839-8789
Mailing Address - Fax:
Practice Address - Street 1:3605 HOSPITAL ROAD
Practice Address - Street 2:
Practice Address - City:ATWATER
Practice Address - State:CA
Practice Address - Zip Code:95301
Practice Address - Country:US
Practice Address - Phone:209-723-1888
Practice Address - Fax:209-723-1858
Is Sole Proprietor?:No
Enumeration Date:2005-10-04
Last Update Date:2016-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARPH54483183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist