Provider Demographics
NPI:1699881250
Name:MADDOX, RANDY (MD)
Entity type:Individual
Prefix:
First Name:RANDY
Middle Name:
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 1:2909 MILITARY RD
Mailing Address - Street 2:
Mailing Address - City:BENTON
Mailing Address - State:AR
Mailing Address - Zip Code:72015-2721
Mailing Address - Country:US
Mailing Address - Phone:501-315-6500
Mailing Address - Fax:501-315-0006
Practice Address - Street 1:2909 MILITARY RD
Practice Address - Street 2:
Practice Address - City:BENTON
Practice Address - State:AR
Practice Address - Zip Code:72015-2721
Practice Address - Country:US
Practice Address - Phone:501-315-6500
Practice Address - Fax:501-315-0006
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARC8131207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ARF78947Medicare UPIN
AR5J377Medicare ID - Type Unspecified