Basic Information
Provider Information | |||||||||
NPI: | 1578722039 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | MADDRY | ||||||||
FirstName: | JOSEPH | ||||||||
MiddleName: |   | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1835 FRANKLIN ST | ||||||||
Address2: |   | ||||||||
City: | DENVER | ||||||||
State: | CO | ||||||||
PostalCode: | 802181126 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3033384545 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 3551 ROGER BROOKE DR | ||||||||
Address2: | QUALITY SERVICES/7TH FLOOR ATTN: MCHE-ZQQ | ||||||||
City: | JBSA FT SAM HOUSTON | ||||||||
State: | TX | ||||||||
PostalCode: | 78234 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2109160808 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/09/2008 | ||||||||
LastUpdateDate: | 09/17/2019 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | 50473 | CO | N |   | Allopathic & Osteopathic Physicians | Emergency Medicine |   | 207PT0002X | P7305 | TX | N |   | Allopathic & Osteopathic Physicians | Emergency Medicine | Medical Toxicology | 207P00000X | P7305 | TX | Y |   | Allopathic & Osteopathic Physicians | Emergency Medicine |   |
ID Information
ID | Type | State | Issuer | Description | 95375511 | 05 | CO |   | MEDICAID | 326992014 | 05 | TX |   | MEDICAID | 022397 | 01 | CO | KAISER COMMERCIAL NUMBER | OTHER | 326992015 | 01 | TX | CSHCN | OTHER |