Provider Demographics
NPI:1225449655
Name:MADDOX, JEREMY LINDSEY (IDC)
Entity Type:Individual
Prefix:
First Name:JEREMY
Middle Name:LINDSEY
Last Name:MADDOX
Suffix:
Gender:M
Credentials:IDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 555412
Mailing Address - Street 2:
Mailing Address - City:CAMP PENDLETON
Mailing Address - State:CA
Mailing Address - Zip Code:92055-5412
Mailing Address - Country:US
Mailing Address - Phone:760-763-1831
Mailing Address - Fax:
Practice Address - Street 1:1/1 BAS 53 AREA
Practice Address - Street 2:
Practice Address - City:CAMP PENDLETON
Practice Address - State:CA
Practice Address - Zip Code:92055-5412
Practice Address - Country:US
Practice Address - Phone:760-763-1831
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-05-20
Last Update Date:2014-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman