Healthcare Provider Details

I. General information

NPI: 1649535824
Provider Name (Legal Business Name): NICHOLAS MADAFFER D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/12/2012
Last Update Date: 11/14/2024
Certification Date: 11/14/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1600 E BROADWAY
COLUMBIA MO
65201-5844
US

IV. Provider business mailing address

1600 E BROADWAY
COLUMBIA MO
65201-5844
US

V. Phone/Fax

Practice location:
  • Phone: 573-815-2700
  • Fax: 573-815-3693
Mailing address:
  • Phone: 573-815-2700
  • Fax: 573-815-3693

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2081P2900X
TaxonomyPain Medicine (Physical Medicine & Rehabilitation) Physician
License Number2017012404
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number2017012404
License Number StateMO
# 3
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number252846
License Number StateMA
# 4
Primary TaxonomyN
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number4665-850
License Number StateWI
# 5
Primary TaxonomyN
Taxonomy Code2081P2900X
TaxonomyPain Medicine (Physical Medicine & Rehabilitation) Physician
License Number301480
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: