Healthcare Provider Details

I. General information

NPI: 1447231311
Provider Name (Legal Business Name): JAMES REGIS MADISON DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/08/2005
Last Update Date: 05/13/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1500 E DOWNING #102
TAHLEQUAH OK
74464
US

IV. Provider business mailing address

PO BOX 1008
TAHLEQUAH OK
74465-1008
US

V. Phone/Fax

Practice location:
  • Phone: 918-207-1189
  • Fax: 918-207-1160
Mailing address:
  • Phone: 918-207-1189
  • Fax: 918-207-1160

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License Number4485
License Number StateOK

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier200114250A
Identifier TypeMEDICAID
Identifier StateOK
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: