Provider Demographics
NPI:1649275736
Name:JOSE L MADARA JR M D PA
Entity type:Organization
Organization Name:JOSE L MADARA JR M D PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JOSE
Authorized Official - Middle Name:LAS LLAGAS
Authorized Official - Last Name:MADARA
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:662-728-7711
Mailing Address - Street 1:102 HOTEL ST
Mailing Address - Street 2:
Mailing Address - City:BOONEVILLE
Mailing Address - State:MS
Mailing Address - Zip Code:38829-3303
Mailing Address - Country:US
Mailing Address - Phone:662-728-7711
Mailing Address - Fax:662-728-7713
Practice Address - Street 1:102 HOTEL ST
Practice Address - Street 2:
Practice Address - City:BOONEVILLE
Practice Address - State:MS
Practice Address - Zip Code:38829-3303
Practice Address - Country:US
Practice Address - Phone:662-728-7711
Practice Address - Fax:662-728-7713
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-16
Last Update Date:2007-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS7928208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00016361Medicaid
MS00016361Medicaid