Provider Demographics
NPI:1598815714
Name:MADDOCKS, RAYMOND A (MD)
Entity Type:Individual
Prefix:
First Name:RAYMOND
Middle Name:A
Last Name:MADDOCKS
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 1:102 PARK STREET
Mailing Address - Street 2:SUITE 201
Mailing Address - City:GLENS FALLS
Mailing Address - State:NY
Mailing Address - Zip Code:12801
Mailing Address - Country:US
Mailing Address - Phone:518-798-1719
Mailing Address - Fax:518-798-1943
Practice Address - Street 1:102 PARK STREET
Practice Address - Street 2:SUITE 201
Practice Address - City:GLENS FALLS
Practice Address - State:NY
Practice Address - Zip Code:12801
Practice Address - Country:US
Practice Address - Phone:518-798-1719
Practice Address - Fax:518-798-1943
Is Sole Proprietor?:No
Enumeration Date:2007-01-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY137920208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00806515Medicaid
30106CMedicare ID - Type Unspecified
NY00806515Medicaid