Provider Demographics
NPI:1306831128
Name:MADDOX, OWEN (MD)
Entity Type:Individual
Prefix:
First Name:OWEN
Middle Name:
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:PO BOX 9135
Mailing Address - Street 2:ATT:SHARON SILVA
Mailing Address - City:BROOKLINE
Mailing Address - State:MA
Mailing Address - Zip Code:02446-9135
Mailing Address - Country:US
Mailing Address - Phone:800-927-0002
Mailing Address - Fax:
Practice Address - Street 1:125 PARKER HILL AVE
Practice Address - Street 2:
Practice Address - City:ROXBURY CROSSING
Practice Address - State:MA
Practice Address - Zip Code:02120-2847
Practice Address - Country:US
Practice Address - Phone:617-754-6687
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-19
Last Update Date:2015-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA207995174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0136191Medicaid
MA0136191Medicaid
E90646Medicare UPIN