Provider Demographics
NPI:1356503833
Name:MADDOX, MICHAEL (MD)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
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 1:1514 JEFFERSON HWY
Mailing Address - Street 2:
Mailing Address - City:NEW ORLEANS
Mailing Address - State:LA
Mailing Address - Zip Code:70121-2483
Mailing Address - Country:US
Mailing Address - Phone:504-842-4000
Mailing Address - Fax:
Practice Address - Street 1:200 W ESPLANADE AVE
Practice Address - Street 2:SUITE 210
Practice Address - City:KENNER
Practice Address - State:LA
Practice Address - Zip Code:70065-2489
Practice Address - Country:US
Practice Address - Phone:504-464-8588
Practice Address - Fax:504-464-8586
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-26
Last Update Date:2015-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAMD.205949208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS02158023Medicaid
LA2339109Medicaid
LA2339109Medicaid