Basic Information
| Provider Information | |||||||||
| NPI: | 1356503833 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MADDOX | ||||||||
| FirstName: | MICHAEL | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1514 JEFFERSON HWY | ||||||||
| Address2: | |||||||||
| City: | NEW ORLEANS | ||||||||
| State: | LA | ||||||||
| PostalCode: | 701212483 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5048424000 | ||||||||
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| Practice Location | |||||||||
| Address1: | 200 W ESPLANADE AVE | ||||||||
| Address2: | SUITE 210 | ||||||||
| City: | KENNER | ||||||||
| State: | LA | ||||||||
| PostalCode: | 700652489 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5044648588 | ||||||||
| FaxNumber: | 5044648586 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/26/2008 | ||||||||
| LastUpdateDate: | 11/17/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208800000X | MD.205949 | LA | Y | Allopathic & Osteopathic Physicians | Urology |
ID Information
| ID | Type | State | Issuer | Description | 02158023 | 05 | MS | MEDICAID | 2339109 | 05 | LA | MEDICAID |