Provider Demographics
NPI:1861828741
Name:MADISON, JUANITA YVETTE
Entity Type:Individual
Prefix:
First Name:JUANITA
Middle Name:YVETTE
Last Name:MADISON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:500 CANARY LN
Mailing Address - Street 2:
Mailing Address - City:DESOTO
Mailing Address - State:TX
Mailing Address - Zip Code:75115-7110
Mailing Address - Country:US
Mailing Address - Phone:214-457-4062
Mailing Address - Fax:469-297-4222
Practice Address - Street 1:500 CANARY LN
Practice Address - Street 2:
Practice Address - City:DESOTO
Practice Address - State:TX
Practice Address - Zip Code:75115-7110
Practice Address - Country:US
Practice Address - Phone:214-457-4062
Practice Address - Fax:469-297-4222
Is Sole Proprietor?:Yes
Enumeration Date:2013-09-23
Last Update Date:2013-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305R00000XManaged Care OrganizationsPreferred Provider Organization