Provider Demographics
NPI:1306414552
Name:MADDOX, JASON MATTHEW
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:MATTHEW
Last Name:MADDOX
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12446 LIGHTHOUSE WAY DR APT E
Mailing Address - Street 2:
Mailing Address - City:CREVE COEUR
Mailing Address - State:MO
Mailing Address - Zip Code:63141-6491
Mailing Address - Country:US
Mailing Address - Phone:314-413-2837
Mailing Address - Fax:
Practice Address - Street 1:12680 OLIVE BLVD STE 300
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63141-6322
Practice Address - Country:US
Practice Address - Phone:314-251-8888
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-15
Last Update Date:2021-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2021021904207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty