Healthcare Provider Details

I. General information

NPI: 1306414552
Provider Name (Legal Business Name): JASON MATTHEW MADDOX
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/15/2021
Last Update Date: 07/24/2024
Certification Date: 07/24/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12680 OLIVE BLVD STE 300
SAINT LOUIS MO
63141-6322
US

IV. Provider business mailing address

PO BOX 776084
CHICAGO IL
60677-6491
US

V. Phone/Fax

Practice location:
  • Phone: 314-251-8888
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number2021021904
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: