Healthcare Provider Details

I. General information

NPI: 1215994868
Provider Name (Legal Business Name): DEMILLE W MADOUX M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/27/2006
Last Update Date: 05/02/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8105 NW EXPRESSWAY
OKLAHOMA CITY OK
73162-6004
US

IV. Provider business mailing address

23990 N MACARTHUR BLVD
EDMOND OK
73025-9455
US

V. Phone/Fax

Practice location:
  • Phone: 405-602-3500
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207PE0004X
TaxonomyEmergency Medical Services (Emergency Medicine) Physician
License Number15810
License Number StateOK
# 2
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number15810
License Number StateOK
# 3
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number15810
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: