Provider Demographics
NPI:1013911031
Name:MADDACK, DONALD JAMES (DO)
Entity type:Individual
Prefix:
First Name:DONALD
Middle Name:JAMES
Last Name:MADDACK
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2675 WINKLER AVE FL 2
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33901-9342
Mailing Address - Country:US
Mailing Address - Phone:877-856-3774
Mailing Address - Fax:
Practice Address - Street 1:901 VENETIA BAY BLVD STE 110
Practice Address - Street 2:
Practice Address - City:VENICE
Practice Address - State:FL
Practice Address - Zip Code:34285-8042
Practice Address - Country:US
Practice Address - Phone:941-484-4778
Practice Address - Fax:941-485-8063
Is Sole Proprietor?:No
Enumeration Date:2005-06-08
Last Update Date:2024-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS17632207Q00000X
IN02001180208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000093873OtherAMTHEM BC/BS
IN080152595OtherRAILROAD MEDICARE
IN100352910Medicaid
IN000000093873OtherAMTHEM BC/BS