Provider Demographics
NPI:1174716997
Name:D. MADDOX, M.D., A PROF. CORP
Entity type:Organization
Organization Name:D. MADDOX, M.D., A PROF. CORP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DENIS
Authorized Official - Middle Name:ERIC
Authorized Official - Last Name:MADDOX
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:661-326-1100
Mailing Address - Street 1:2901 SILLECT AVE STE 200
Mailing Address - Street 2:
Mailing Address - City:BAKERSFIELD
Mailing Address - State:CA
Mailing Address - Zip Code:93308-6370
Mailing Address - Country:US
Mailing Address - Phone:661-326-1100
Mailing Address - Fax:
Practice Address - Street 1:2901 SILLECT AVE STE 200
Practice Address - Street 2:
Practice Address - City:BAKERSFIELD
Practice Address - State:CA
Practice Address - Zip Code:93308-6370
Practice Address - Country:US
Practice Address - Phone:661-326-1100
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-24
Last Update Date:2009-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG24697174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CADN8120OtherGROUP RAILROAD
CAZZZ05742ZOtherMEDICARE PTAN
CA00G246970Medicaid
CA00G246970Medicaid
CADN8120OtherGROUP RAILROAD