Provider Demographics
NPI:1346335833
Name:MADDOX, VELVET JETER (OD)
Entity Type:Individual
Prefix:DR
First Name:VELVET
Middle Name:JETER
Last Name:MADDOX
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:607-C BOLL WEEVIL CIRCLE
Mailing Address - Street 2:
Mailing Address - City:ENTERPRISE
Mailing Address - State:AL
Mailing Address - Zip Code:36330
Mailing Address - Country:US
Mailing Address - Phone:334-347-6599
Mailing Address - Fax:334-347-6599
Practice Address - Street 1:607-C BOLL WEEVIL CIRCLE
Practice Address - Street 2:
Practice Address - City:ENTERPRISE
Practice Address - State:AL
Practice Address - Zip Code:36330
Practice Address - Country:US
Practice Address - Phone:334-347-6599
Practice Address - Fax:334-347-6599
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-03
Last Update Date:2011-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALALS-686TA163152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL000058532Medicaid
AL000058532Medicaid
ALT87424Medicare UPIN
AL51058532Medicare ID - Type Unspecified