Provider Demographics
NPI:1588267355
Name:MADDOX, MITCHELL (MD)
Entity type:Individual
Prefix:
First Name:MITCHELL
Middle Name:
Last Name:MADDOX
Suffix:
Gender:
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1401 SW 34TH ST
Mailing Address - Street 2:
Mailing Address - City:MOORE
Mailing Address - State:OK
Mailing Address - Zip Code:73160-3059
Mailing Address - Country:US
Mailing Address - Phone:405-793-1188
Mailing Address - Fax:405-793-0492
Practice Address - Street 1:1401 SW 34TH ST
Practice Address - Street 2:
Practice Address - City:MOORE
Practice Address - State:OK
Practice Address - Zip Code:73160-3059
Practice Address - Country:US
Practice Address - Phone:405-793-1188
Practice Address - Fax:405-793-0492
Is Sole Proprietor?:No
Enumeration Date:2020-11-16
Last Update Date:2025-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK39530207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine