MEDICARE: ROBERT K MADDOCK JR. MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207R00000X	Internal Medicine Physician	148967-1205	UT

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	148967-1205	OTHER	UT	PHYSICIAN & SURG LIC #

General Provider Information

NPI Number	:	1306951975
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ROBERT K MADDOCK JR. MD

Provider Business Mailing Address
First Line	:	2553 BEVERLY ST
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84106-3118
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2553 BEVERLY ST
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84106-3118
Country	:	US
Telephone Number	:	801-485-5445
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/21/2006
Last Update Date	:	03/07/2023

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