Healthcare Provider Details

I. General information

NPI: 1104801208
Provider Name (Legal Business Name): JOHN MARK MADDOX M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/12/2005
Last Update Date: 12/07/2022
Certification Date: 12/07/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1145 BROADWAY STE 300
TACOMA WA
98402-3523
US

IV. Provider business mailing address

1145 BROADWAY STE 300
TACOMA WA
98402-3523
US

V. Phone/Fax

Practice location:
  • Phone: 253-403-1130
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number133071
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberMD24744
License Number StateOR
# 3
Primary TaxonomyN
Taxonomy Code208C00000X
TaxonomyColon & Rectal Surgery Physician
License Number133071
License Number StateCA
# 4
Primary TaxonomyN
Taxonomy Code208C00000X
TaxonomyColon & Rectal Surgery Physician
License NumberMD24744
License Number StateOR
# 5
Primary TaxonomyY
Taxonomy Code208C00000X
TaxonomyColon & Rectal Surgery Physician
License NumberMD60662688
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: