Basic Information
| Provider Information | |||||||||
| NPI: | 1992871321 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MADDOX | ||||||||
| FirstName: | TY | ||||||||
| MiddleName: | CARL | ||||||||
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| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2021 N MACARTHUR BLVD | ||||||||
| Address2: | SUITE 150 | ||||||||
| City: | IRVING | ||||||||
| State: | TX | ||||||||
| PostalCode: | 750612219 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9722532560 | ||||||||
| FaxNumber: | 9722534218 | ||||||||
| Practice Location | |||||||||
| Address1: | 2021 N MACARTHUR BLVD | ||||||||
| Address2: | SUITE 350 | ||||||||
| City: | IRVING | ||||||||
| State: | TX | ||||||||
| PostalCode: | 750612219 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9722532500 | ||||||||
| FaxNumber: | 9722534227 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/28/2006 | ||||||||
| LastUpdateDate: | 03/02/2017 | ||||||||
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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 | 207R00000X | L5445 | TX | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 163003001 | 05 | TX | MEDICAID |