Provider Demographics
NPI:1376739953
Name:MADARA, JOSE L JR
Entity Type:Individual
Prefix:
First Name:JOSE
Middle Name:L
Last Name:MADARA
Suffix:JR
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 1:102 HOTEL ST
Mailing Address - Street 2:
Mailing Address - City:BOONEVILLE
Mailing Address - State:MS
Mailing Address - Zip Code:38829-3303
Mailing Address - Country:US
Mailing Address - Phone:662-728-7711
Mailing Address - Fax:661-728-7713
Practice Address - Street 1:102 HOTEL ST
Practice Address - Street 2:
Practice Address - City:BOONEVILLE
Practice Address - State:MS
Practice Address - Zip Code:38829-3303
Practice Address - Country:US
Practice Address - Phone:662-728-7711
Practice Address - Fax:661-728-7713
Is Sole Proprietor?:Yes
Enumeration Date:2007-09-18
Last Update Date:2007-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS7928208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MSB64960Medicare UPIN