Provider Demographics
NPI:1083680342
Name:MADDOX, STEPHEN J JR (MD)
Entity Type:Individual
Prefix:
First Name:STEPHEN
Middle Name:J
Last Name:MADDOX
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:160 ROBBINS ST
Mailing Address - Street 2:
Mailing Address - City:WATERBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06708-2652
Mailing Address - Country:US
Mailing Address - Phone:203-755-2999
Mailing Address - Fax:203-755-6782
Practice Address - Street 1:160 ROBBINS ST
Practice Address - Street 2:
Practice Address - City:WATERBURY
Practice Address - State:CT
Practice Address - Zip Code:06708-2652
Practice Address - Country:US
Practice Address - Phone:203-755-2999
Practice Address - Fax:203-755-6782
Is Sole Proprietor?:No
Enumeration Date:2006-02-27
Last Update Date:2016-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY230823208000000X
CT045563208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT008016138Medicaid
CT045563OtherPHYSICIAN LICENSE
CT008016138Medicaid