Provider Demographics
NPI:1790795276
Name:MADDEN, JOHN B (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:B
Last Name:MADDEN
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 1:4290 LAKELAND DR STE A
Mailing Address - Street 2:
Mailing Address - City:FLOWOOD
Mailing Address - State:MS
Mailing Address - Zip Code:39232-9571
Mailing Address - Country:US
Mailing Address - Phone:601-932-0083
Mailing Address - Fax:
Practice Address - Street 1:4290 LAKELAND DR STE A
Practice Address - Street 2:
Practice Address - City:FLOWOOD
Practice Address - State:MS
Practice Address - Zip Code:39232-9571
Practice Address - Country:US
Practice Address - Phone:601-932-0083
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-08
Last Update Date:2020-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS18603207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS04904314Medicaid
MSI40299Medicare UPIN
MS080004131Medicare PIN