Provider Demographics
NPI:1083903785
Name:MADDEN, NICHOLAS ANDREW (MD)
Entity Type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:ANDREW
Last Name:MADDEN
Suffix:
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 1:1001 E PRIMROSE ST
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65807-5155
Mailing Address - Country:US
Mailing Address - Phone:417-875-3462
Mailing Address - Fax:
Practice Address - Street 1:3850 S NATIONAL AVE
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65807-5287
Practice Address - Country:US
Practice Address - Phone:174-269-6115
Practice Address - Fax:417-269-6679
Is Sole Proprietor?:No
Enumeration Date:2011-04-04
Last Update Date:2019-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
MO20190170452085R0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation Oncology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO200070335Medicaid