Provider Demographics
NPI:1861805921
Name:MADAN, OLIVIA PENN (MD)
Entity type:Individual
Prefix:DR
First Name:OLIVIA
Middle Name:PENN
Last Name:MADAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:905 S HAWTHORNE RD
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27103-4416
Mailing Address - Country:US
Mailing Address - Phone:864-650-6228
Mailing Address - Fax:
Practice Address - Street 1:1914 CHARLOTTE AVE STE 101
Practice Address - Street 2:
Practice Address - City:NASHVILLE
Practice Address - State:TN
Practice Address - Zip Code:37203-2231
Practice Address - Country:US
Practice Address - Phone:615-327-0303
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-06
Last Update Date:2021-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN60988208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN1659549608OtherPRACTICE NPI