Healthcare Provider Details

I. General information

NPI: 1063109783
Provider Name (Legal Business Name): MARKIA MADDOX
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/21/2023
Last Update Date: 03/26/2024
Certification Date: 10/23/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6045 CREEKFORD DR
LITHONIA GA
30058-7960
US

IV. Provider business mailing address

8170 MALL PKWY # 1573
LITHONIA GA
30038-2545
US

V. Phone/Fax

Practice location:
  • Phone: 404-965-0775
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QH0100X
TaxonomyHealth Service Clinic/Center
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code246RP1900X
TaxonomyPhlebotomy Technician
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: