Provider Demographics
NPI:1932719531
Name:OLDHAM, MADISON (CO)
Entity Type:Individual
Prefix:
First Name:MADISON
Middle Name:
Last Name:OLDHAM
Suffix:
Gender:F
Credentials:CO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:470 COPPERFIELD BLVD NE
Mailing Address - Street 2:
Mailing Address - City:CONCORD
Mailing Address - State:NC
Mailing Address - Zip Code:28025-2404
Mailing Address - Country:US
Mailing Address - Phone:704-782-0908
Mailing Address - Fax:704-786-0469
Practice Address - Street 1:470 COPPERFIELD BLVD NE
Practice Address - Street 2:
Practice Address - City:CONCORD
Practice Address - State:NC
Practice Address - Zip Code:28025-2404
Practice Address - Country:US
Practice Address - Phone:704-782-0908
Practice Address - Fax:704-786-0469
Is Sole Proprietor?:No
Enumeration Date:2020-08-07
Last Update Date:2020-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCCO006216222Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOrthotist