Provider Demographics
NPI:1821060328
Name:MADDOCK, STEPHEN WILLIAM (MD, PHD)
Entity Type:Individual
Prefix:DR
First Name:STEPHEN
Middle Name:WILLIAM
Last Name:MADDOCK
Suffix:
Gender:M
Credentials:MD, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:70 E WINDSOR BLVD
Mailing Address - Street 2:
Mailing Address - City:WINDSOR
Mailing Address - State:VA
Mailing Address - Zip Code:23487-9443
Mailing Address - Country:US
Mailing Address - Phone:757-242-9191
Mailing Address - Fax:
Practice Address - Street 1:70 E WINDSOR BLVD
Practice Address - Street 2:
Practice Address - City:WINDSOR
Practice Address - State:VA
Practice Address - Zip Code:23487-9443
Practice Address - Country:US
Practice Address - Phone:757-242-9191
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-07
Last Update Date:2008-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101233391208D00000X
IN01057012A208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
H75515Medicare UPIN
00V254S37Medicare ID - Type Unspecified