Healthcare Provider Details

I. General information

NPI: 1225001589
Provider Name (Legal Business Name): BRUCE R MADDERN MD PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/08/2006
Last Update Date: 09/07/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10475 CENTURION PKWY N SUITE 302
JACKSONVILLE FL
32256-5003
US

IV. Provider business mailing address

10475 CENTURION PKWY N SUITE 302
JACKSONVILLE FL
32256-5003
US

V. Phone/Fax

Practice location:
  • Phone: 904-398-5437
  • Fax: 904-398-3077
Mailing address:
  • Phone: 904-398-5437
  • Fax: 904-398-3077

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207YX0905X
TaxonomyOtolaryngology/Facial Plastic Surgery Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207YP0228X
TaxonomyPediatric Otolaryngology Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. BRUCE R MADDERN
Title or Position: PRESIDENT
Credential: MD
Phone: 904-398-5437