Provider Demographics
NPI:1356305536
Name:MADDOX, TRUETT LAYTON (MD)
Entity Type:Individual
Prefix:DR
First Name:TRUETT
Middle Name:LAYTON
Last Name:MADDOX
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:TRUETT
Other - Middle Name:LAYTON
Other - Last Name:MADDOX
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:405 W COUNTRY CLUB RD
Mailing Address - Street 2:
Mailing Address - City:ROSWELL
Mailing Address - State:NM
Mailing Address - Zip Code:88201-5209
Mailing Address - Country:US
Mailing Address - Phone:575-624-4777
Mailing Address - Fax:575-624-8711
Practice Address - Street 1:405 W COUNTRY CLUB RD
Practice Address - Street 2:
Practice Address - City:ROSWELL
Practice Address - State:NM
Practice Address - Zip Code:88201-5209
Practice Address - Country:US
Practice Address - Phone:575-624-4777
Practice Address - Fax:575-624-8711
Is Sole Proprietor?:No
Enumeration Date:2006-04-14
Last Update Date:2020-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM912462084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMNM001X06OtherBCBS
NMW3115Medicaid
NMB24555Medicare UPIN
NM342711603Medicare PIN