Provider Demographics
NPI:1578023362
Name:MADDY, AUSTIN JOHN
Entity type:Individual
Prefix:
First Name:AUSTIN
Middle Name:JOHN
Last Name:MADDY
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1025 MAINE ST
Mailing Address - Street 2:
Mailing Address - City:QUINCY
Mailing Address - State:IL
Mailing Address - Zip Code:62301-4096
Mailing Address - Country:US
Mailing Address - Phone:217-222-6550
Mailing Address - Fax:
Practice Address - Street 1:1025 MAINE ST
Practice Address - Street 2:
Practice Address - City:QUINCY
Practice Address - State:IL
Practice Address - Zip Code:62301-4096
Practice Address - Country:US
Practice Address - Phone:217-222-6550
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-20
Last Update Date:2025-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036174529207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology