Provider Demographics
NPI:1922478239
Name:MADDOCKS, ADAM LARRY (OD)
Entity Type:Individual
Prefix:DR
First Name:ADAM
Middle Name:LARRY
Last Name:MADDOCKS
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1150 S 100 W
Mailing Address - Street 2:
Mailing Address - City:LOGAN
Mailing Address - State:UT
Mailing Address - Zip Code:84321-5573
Mailing Address - Country:US
Mailing Address - Phone:435-754-3459
Mailing Address - Fax:435-787-8498
Practice Address - Street 1:1150 S 100 W
Practice Address - Street 2:
Practice Address - City:LOGAN
Practice Address - State:UT
Practice Address - Zip Code:84321-5573
Practice Address - Country:US
Practice Address - Phone:435-754-3459
Practice Address - Fax:435-787-8498
Is Sole Proprietor?:No
Enumeration Date:2015-09-29
Last Update Date:2019-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT10295884-9934152W00000X
MI4901004935152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT10295884-9934OtherUTAH DEPARTMENT OF COMMERCE, DIVISION OF OCCUPATIONAL AND PROFESSIONAL LICENSING
MI4901004935OtherMICHIGAN DEPARTMENT OF LICENSING AND REGULATORY AFFAIRS, BOARD OF OPTOMETRY