Provider Demographics
NPI:1538905161
Name:MADDOCK, CALEB
Entity type:Individual
Prefix:
First Name:CALEB
Middle Name:
Last Name:MADDOCK
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 1:2158 S SANDUSKY AVE
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74114-2134
Mailing Address - Country:US
Mailing Address - Phone:479-684-6626
Mailing Address - Fax:
Practice Address - Street 1:6802 S OLYMPIA AVE
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74132-1823
Practice Address - Country:US
Practice Address - Phone:918-488-2280
Practice Address - Fax:918-488-2285
Is Sole Proprietor?:Yes
Enumeration Date:2024-07-03
Last Update Date:2024-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK6339225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist