Provider Demographics
NPI:1528104486
Name:MADDOX, MICHAEL WAYNE (MD)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:WAYNE
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:PO BOX 370
Mailing Address - Street 2:
Mailing Address - City:VALLECITO
Mailing Address - State:CA
Mailing Address - Zip Code:95251-0370
Mailing Address - Country:US
Mailing Address - Phone:951-212-2777
Mailing Address - Fax:775-854-6449
Practice Address - Street 1:4141 RED HILL RD
Practice Address - Street 2:
Practice Address - City:VALLECITO
Practice Address - State:CA
Practice Address - Zip Code:95251
Practice Address - Country:US
Practice Address - Phone:951-212-2777
Practice Address - Fax:775-854-6449
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG755932084P0804X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry