Provider Demographics
NPI:1447231311
Name:MADISON, JAMES REGIS (DO)
Entity Type:Individual
Prefix:DR
First Name:JAMES
Middle Name:REGIS
Last Name:MADISON
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1008
Mailing Address - Street 2:
Mailing Address - City:TAHLEQUAH
Mailing Address - State:OK
Mailing Address - Zip Code:74465-1008
Mailing Address - Country:US
Mailing Address - Phone:918-207-1189
Mailing Address - Fax:918-207-1160
Practice Address - Street 1:1500 E DOWNING #102
Practice Address - Street 2:
Practice Address - City:TAHLEQUAH
Practice Address - State:OK
Practice Address - Zip Code:74464
Practice Address - Country:US
Practice Address - Phone:918-207-1189
Practice Address - Fax:918-207-1160
Is Sole Proprietor?:No
Enumeration Date:2005-11-08
Last Update Date:2010-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK4485207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200114250AMedicaid
OK243727506Medicare PIN
OK200114250AMedicaid
OKOK403699Medicare PIN