Provider Demographics
NPI:1649535824
Name:MADAFFER, NICHOLAS (DO)
Entity type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:
Last Name:MADAFFER
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1600 E BROADWAY
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:MO
Mailing Address - Zip Code:65201-5844
Mailing Address - Country:US
Mailing Address - Phone:573-815-2700
Mailing Address - Fax:573-815-3693
Practice Address - Street 1:1600 E BROADWAY
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:MO
Practice Address - Zip Code:65201-5844
Practice Address - Country:US
Practice Address - Phone:573-815-2700
Practice Address - Fax:573-815-3693
Is Sole Proprietor?:No
Enumeration Date:2012-07-12
Last Update Date:2024-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20170124042081P2900X, 208100000X
MA252846207R00000X
WI4665-850208100000X
LA3014802081P2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
No2081P2900XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationPain Medicine
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine