Basic Information
| Provider Information | |||||||||
| NPI: | 1578558094 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MADDOX | ||||||||
| FirstName: | HEATHER | ||||||||
| MiddleName: | E | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | P.O. BOX 7609 | ||||||||
| Address2: | |||||||||
| City: | MISSOULA | ||||||||
| State: | MT | ||||||||
| PostalCode: | 598077609 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4067215600 | ||||||||
| FaxNumber: | 4067213907 | ||||||||
| Practice Location | |||||||||
| Address1: | 500 W. BROADWAY | ||||||||
| Address2: | |||||||||
| City: | MISSOULA | ||||||||
| State: | MT | ||||||||
| PostalCode: | 598024003 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4067215600 | ||||||||
| FaxNumber: | 4067213907 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/12/2005 | ||||||||
| LastUpdateDate: | 01/11/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 0101231026 | VA | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | 11962 | MT | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 010003105 | 05 | VA | MEDICAID |