Provider Demographics
NPI:1902667629
Name:MADDOX, CHASE MONTGOMERY
Entity Type:Individual
Prefix:MR
First Name:CHASE
Middle Name:MONTGOMERY
Last Name:MADDOX
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:517 W 161ST ST APT 65
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10032-6115
Mailing Address - Country:US
Mailing Address - Phone:347-894-7025
Mailing Address - Fax:
Practice Address - Street 1:1623 FLATBUSH AVE STE 4
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11210-3264
Practice Address - Country:US
Practice Address - Phone:718-377-5755
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-01-19
Last Update Date:2024-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYNYCPS-P-200062175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist