Provider Demographics
NPI:1497807234
Name:MADDOX, ROBERT P JR (DC)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:P
Last Name:MADDOX
Suffix:JR
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1100 N STATE ROAD 135
Mailing Address - Street 2:SUITE BCD
Mailing Address - City:GREENWOOD
Mailing Address - State:IN
Mailing Address - Zip Code:46142-1034
Mailing Address - Country:US
Mailing Address - Phone:317-881-6013
Mailing Address - Fax:317-881-1395
Practice Address - Street 1:1100 N STATE ROAD 135
Practice Address - Street 2:SUITE BCD
Practice Address - City:GREENWOOD
Practice Address - State:IN
Practice Address - Zip Code:46142-1034
Practice Address - Country:US
Practice Address - Phone:317-881-6013
Practice Address - Fax:317-881-1395
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN08000602A111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
000000198008OtherANTHEM PROVIDER #
IN6003957OtherUSAA #
08000602OtherLICENSE #
606OtherWORK COMP #
08000602OtherLICENSE #
IN075840Medicare ID - Type Unspecified