Provider Demographics
NPI:1396974093
Name:MADDOX, AUDREY JANE I (MD)
Entity type:Individual
Prefix:
First Name:AUDREY JANE
Middle Name:I
Last Name:MADDOX
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:222 PERRY HWY
Mailing Address - Street 2:
Mailing Address - City:HAWKINSVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:31036-6748
Mailing Address - Country:US
Mailing Address - Phone:478-783-4080
Mailing Address - Fax:
Practice Address - Street 1:173 W DYKES ST STE 102
Practice Address - Street 2:
Practice Address - City:COCHRAN
Practice Address - State:GA
Practice Address - Zip Code:31014-6921
Practice Address - Country:US
Practice Address - Phone:478-934-0329
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-07-02
Last Update Date:2012-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCLL31769208000000X
GA067679208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA067679OtherGA COMPOSITE MEDICAL BOARD