Provider Demographics
NPI:1417194689
Name:MADDUX, JONATHAN PATMOR (MD)
Entity Type:Individual
Prefix:
First Name:JONATHAN
Middle Name:PATMOR
Last Name:MADDUX
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 559
Mailing Address - Street 2:
Mailing Address - City:MARION
Mailing Address - State:KY
Mailing Address - Zip Code:42064-0559
Mailing Address - Country:US
Mailing Address - Phone:270-965-5238
Mailing Address - Fax:270-965-9015
Practice Address - Street 1:518 WEST GUM STREET
Practice Address - Street 2:
Practice Address - City:MARION
Practice Address - State:KY
Practice Address - Zip Code:42064-1516
Practice Address - Country:US
Practice Address - Phone:270-965-5238
Practice Address - Fax:270-965-9015
Is Sole Proprietor?:No
Enumeration Date:2009-01-09
Last Update Date:2011-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY44671207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100172480Medicaid
KY000000723351OtherANTHEM BLUE CROSS/BLUE SHIELD
KY7100172480Medicaid