Provider Demographics
NPI:1992871321
Name:MADDOX, TY CARL (DO)
Entity type:Individual
Prefix:
First Name:TY
Middle Name:CARL
Last Name:MADDOX
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2021 N MACARTHUR BLVD
Mailing Address - Street 2:SUITE 150
Mailing Address - City:IRVING
Mailing Address - State:TX
Mailing Address - Zip Code:75061-2219
Mailing Address - Country:US
Mailing Address - Phone:972-253-2560
Mailing Address - Fax:972-253-4218
Practice Address - Street 1:2021 N MACARTHUR BLVD
Practice Address - Street 2:SUITE 350
Practice Address - City:IRVING
Practice Address - State:TX
Practice Address - Zip Code:75061-2219
Practice Address - Country:US
Practice Address - Phone:972-253-2500
Practice Address - Fax:972-253-4227
Is Sole Proprietor?:No
Enumeration Date:2006-11-28
Last Update Date:2017-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL5445207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX163003001Medicaid
TX163003001Medicaid
TX8B3642Medicare PIN