Provider Demographics
NPI:1255368445
Name:MADDEN, JEFFREY W (MD)
Entity type:Individual
Prefix:
First Name:JEFFREY
Middle Name:W
Last Name:MADDEN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:527 MEDICAL PARK DR
Mailing Address - Street 2:SUITE 202
Mailing Address - City:BRIDGEPORT
Mailing Address - State:WV
Mailing Address - Zip Code:26330-9009
Mailing Address - Country:US
Mailing Address - Phone:304-933-3855
Mailing Address - Fax:304-933-3859
Practice Address - Street 1:527 MEDICAL PARK DR
Practice Address - Street 2:SUITE 202
Practice Address - City:BRIDGEPORT
Practice Address - State:WV
Practice Address - Zip Code:26330-9007
Practice Address - Country:US
Practice Address - Phone:304-933-3850
Practice Address - Fax:304-933-3859
Is Sole Proprietor?:No
Enumeration Date:2006-06-26
Last Update Date:2022-04-05
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
WV20432208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA001721899OtherBLUE CROSS PROVIDER NUMBE
WV550748648OtherTAX IDENTIFICATION
WV2002872000Medicaid
WV4047551Medicare ID - Type Unspecified
WV2002872000Medicaid