Provider Demographics
NPI:1093769002
Name:MADDOX, DONALD JEROME (MD)
Entity Type:Individual
Prefix:DR
First Name:DONALD
Middle Name:JEROME
Last Name:MADDOX
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 1:1091 MALLARD CIR
Mailing Address - Street 2:
Mailing Address - City:BOGART
Mailing Address - State:GA
Mailing Address - Zip Code:30622-2765
Mailing Address - Country:US
Mailing Address - Phone:706-310-0063
Mailing Address - Fax:
Practice Address - Street 1:1325 SPRING ST
Practice Address - Street 2:
Practice Address - City:GREENWOOD
Practice Address - State:SC
Practice Address - Zip Code:29646-3860
Practice Address - Country:US
Practice Address - Phone:864-725-4799
Practice Address - Fax:864-725-4707
Is Sole Proprietor?:No
Enumeration Date:2006-05-22
Last Update Date:2008-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC21312207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCG41458Medicaid
SCG41458Medicaid
SCG67928Medicare UPIN