Provider Demographics
NPI:1376328955
Name:PHILLIPS, MADISON JAMES
Entity Type:Individual
Prefix:
First Name:MADISON
Middle Name:JAMES
Last Name:PHILLIPS
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 1:412 E OKLAHOMA ST
Mailing Address - Street 2:
Mailing Address - City:WALTERS
Mailing Address - State:OK
Mailing Address - Zip Code:73572-1622
Mailing Address - Country:US
Mailing Address - Phone:580-559-6133
Mailing Address - Fax:
Practice Address - Street 1:412 E OKLAHOMA ST
Practice Address - Street 2:
Practice Address - City:WALTERS
Practice Address - State:OK
Practice Address - Zip Code:73572-1622
Practice Address - Country:US
Practice Address - Phone:580-559-6133
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-30
Last Update Date:2023-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist