Provider Demographics
NPI:1528946720
Name:MADISON, DARRELL JR
Entity type:Individual
Prefix:
First Name:DARRELL
Middle Name:
Last Name:MADISON
Suffix:JR
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 1:115 DESTRY RD
Mailing Address - Street 2:
Mailing Address - City:ROLAND
Mailing Address - State:OK
Mailing Address - Zip Code:74954-5269
Mailing Address - Country:US
Mailing Address - Phone:479-651-8266
Mailing Address - Fax:479-651-8266
Practice Address - Street 1:115 DESTRY RD
Practice Address - Street 2:
Practice Address - City:ROLAND
Practice Address - State:OK
Practice Address - Zip Code:74954-5269
Practice Address - Country:US
Practice Address - Phone:479-651-8266
Practice Address - Fax:479-651-8266
Is Sole Proprietor?:Yes
Enumeration Date:2025-08-25
Last Update Date:2025-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK2010225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Multi-Specialty