Provider Demographics
NPI:1528553716
Name:MADDOX, STANFORD JAMES
Entity type:Individual
Prefix:
First Name:STANFORD
Middle Name:JAMES
Last Name:MADDOX
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2250 OAK RD UNIT 815
Mailing Address - Street 2:
Mailing Address - City:SNELLVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30078-1905
Mailing Address - Country:US
Mailing Address - Phone:770-899-6364
Mailing Address - Fax:
Practice Address - Street 1:2250 OAK RD UNIT 815
Practice Address - Street 2:
Practice Address - City:SNELLVILLE
Practice Address - State:GA
Practice Address - Zip Code:30078-1905
Practice Address - Country:US
Practice Address - Phone:770-899-6364
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-29
Last Update Date:2020-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA171W00000X
261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171W00000XOther Service ProvidersContractorGroup - Multi-Specialty
No261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical TherapyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA455255557OtherBUSINESS INFO