Provider Demographics
NPI:1356423560
Name:MADDOX, MIKE D (DC, CCST)
Entity type:Individual
Prefix:DR
First Name:MIKE
Middle Name:D
Last Name:MADDOX
Suffix:
Gender:M
Credentials:DC, CCST
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Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:500 CANYON RIDGE DRIVE
Mailing Address - Street 2:SUITE 200 F
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78753-1659
Mailing Address - Country:US
Mailing Address - Phone:512-339-6565
Mailing Address - Fax:512-339-9248
Practice Address - Street 1:500 CANYON RIDGE DRIVE
Practice Address - Street 2:SUITE 200 F
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78753-1659
Practice Address - Country:US
Practice Address - Phone:512-339-6565
Practice Address - Fax:512-339-9248
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-19
Last Update Date:2014-07-01
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
TX4162DC111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX601720Medicare UPIN