Provider Demographics
NPI:1598769077
Name:MADSON, DERALD L (MD)
Entity Type:Individual
Prefix:DR
First Name:DERALD
Middle Name:L
Last Name:MADSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:3964 FRAZEYSBURG RD
Mailing Address - Street 2:
Mailing Address - City:ZANESVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:43701-8924
Mailing Address - Country:US
Mailing Address - Phone:740-455-4944
Mailing Address - Fax:740-450-6199
Practice Address - Street 1:3964 FRAZEYSBURG RD
Practice Address - Street 2:
Practice Address - City:ZANESVILLE
Practice Address - State:OH
Practice Address - Zip Code:43701-8924
Practice Address - Country:US
Practice Address - Phone:740-455-4944
Practice Address - Fax:740-450-6199
Is Sole Proprietor?:No
Enumeration Date:2005-06-13
Last Update Date:2013-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH350593882086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH311661239026OtherCARESOURCE
OH000000122822OtherANTHEM
OH2131955Medicaid
OH311661239026OtherCARESOURCE
OH0890322Medicare PIN
OH$$$$$$$$$00OtherWORKERS COMPENSATION