Basic Information
| Provider Information | |||||||||
| NPI: | 1922478239 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MADDOCKS | ||||||||
| FirstName: | ADAM | ||||||||
| MiddleName: | LARRY | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | O.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1150 S 100 W | ||||||||
| Address2: | |||||||||
| City: | LOGAN | ||||||||
| State: | UT | ||||||||
| PostalCode: | 843215573 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4357543459 | ||||||||
| FaxNumber: | 4357878498 | ||||||||
| Practice Location | |||||||||
| Address1: | 1150 S 100 W | ||||||||
| Address2: | |||||||||
| City: | LOGAN | ||||||||
| State: | UT | ||||||||
| PostalCode: | 843215573 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4357543459 | ||||||||
| FaxNumber: | 4357878498 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/29/2015 | ||||||||
| LastUpdateDate: | 02/25/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | 10295884-9934 | UT | Y | Eye and Vision Services Providers | Optometrist | 152W00000X | 4901004935 | MI | N | Eye and Vision Services Providers | Optometrist |
ID Information
| ID | Type | State | Issuer | Description | 10295884-9934 | 01 | UT | UTAH DEPARTMENT OF COMMERCE, DIVISION OF OCCUPATIONAL AND PROFESSIONAL LICENSING | OTHER | 4901004935 | 01 | MI | MICHIGAN DEPARTMENT OF LICENSING AND REGULATORY AFFAIRS, BOARD OF OPTOMETRY | OTHER |