Provider Demographics
NPI:1790837508
Name:MADDOX, JOHN L (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:L
Last Name:MADDOX
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 1:1300 S ELISEO DR STE 207
Mailing Address - Street 2:
Mailing Address - City:GREENBRAE
Mailing Address - State:CA
Mailing Address - Zip Code:94904-2015
Mailing Address - Country:US
Mailing Address - Phone:415-925-0550
Mailing Address - Fax:415-925-9062
Practice Address - Street 1:1300 S ELISEO DR STE 207
Practice Address - Street 2:
Practice Address - City:GREENBRAE
Practice Address - State:CA
Practice Address - Zip Code:94904-2015
Practice Address - Country:US
Practice Address - Phone:415-925-0550
Practice Address - Fax:415-925-9062
Is Sole Proprietor?:No
Enumeration Date:2007-01-18
Last Update Date:2015-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG40606207N00000X, 207NP0225X, 207NS0135X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
No207NP0225XAllopathic & Osteopathic PhysiciansDermatologyPediatric Dermatology
No207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural Dermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G406060Medicaid
CAG40606Medicare PIN
E65774Medicare UPIN