Provider Demographics
NPI:1265534226
Name:MADDOX, DAVID A (MD)
Entity type:Individual
Prefix:DR
First Name:DAVID
Middle Name:A
Last Name:MADDOX
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 E LIBERTY ST
Mailing Address - Street 2:SUITE 800
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40202-1434
Mailing Address - Country:US
Mailing Address - Phone:502-845-5672
Mailing Address - Fax:502-845-1402
Practice Address - Street 1:150 FAIRVIEW CT
Practice Address - Street 2:
Practice Address - City:EMINENCE
Practice Address - State:KY
Practice Address - Zip Code:40019-1158
Practice Address - Country:US
Practice Address - Phone:502-845-5672
Practice Address - Fax:502-845-1402
Is Sole Proprietor?:No
Enumeration Date:2006-09-01
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY25251207P00000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64252513Medicaid
KY25251OtherKY LICENSE
BM1135119OtherDEA
KY64252513Medicaid
E70874Medicare UPIN