Provider Demographics
NPI:1023562816
Name:MADDOX, BOBBY GERALD III (DPT)
Entity Type:Individual
Prefix:
First Name:BOBBY
Middle Name:GERALD
Last Name:MADDOX
Suffix:III
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2714 W OXFORD LOOP
Mailing Address - Street 2:STE 164
Mailing Address - City:OXFORD
Mailing Address - State:MS
Mailing Address - Zip Code:38655-5711
Mailing Address - Country:US
Mailing Address - Phone:662-232-8949
Mailing Address - Fax:662-232-8950
Practice Address - Street 1:171 LAKEWOOD DR
Practice Address - Street 2:SUITE 2
Practice Address - City:BATESVILLE
Practice Address - State:MS
Practice Address - Zip Code:38606-3011
Practice Address - Country:US
Practice Address - Phone:662-563-2579
Practice Address - Fax:662-563-2580
Is Sole Proprietor?:No
Enumeration Date:2016-08-09
Last Update Date:2016-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSPT5931225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist