1225257017 NPI number — MISTY ZELK, M.D., P.L.L.C.

Table of content: (NPI 1225257017)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1225257017 NPI number — MISTY ZELK, M.D., P.L.L.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MISTY ZELK, M.D., P.L.L.C.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1225257017
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/05/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
11908 KANIS RD
Provider Second Line Business Mailing Address:
SUITE G-8
Provider Business Mailing Address City Name:
LITTLE ROCK
Provider Business Mailing Address State Name:
AR
Provider Business Mailing Address Postal Code:
72211-3733
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
501-225-9990
Provider Business Mailing Address Fax Number:
501-225-9998

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
11908 KANIS RD
Provider Second Line Business Practice Location Address:
SUITE G-8
Provider Business Practice Location Address City Name:
LITTLE ROCK
Provider Business Practice Location Address State Name:
AR
Provider Business Practice Location Address Postal Code:
72211-3733
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
501-225-9990
Provider Business Practice Location Address Fax Number:
501-225-9998
Provider Enumeration Date:
04/24/2007

Additional Information

Authorized Official

Authorized Official Last Name:
HARTER
Authorized Official First Name:
SHANNON
Authorized Official Middle Name:
A
Authorized Official Title or Position:
CLINIC MANAGER
Authorized Official Telephone Number:
501-225-9990

Provider Taxonomy Codes

  • Taxonomy code: 363L00000X , with the licence number:  A01721 , registered in the state of AR ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 174400000X , with the licence number: E1505 , registered in the state of AR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1962401463 . This is a "ZELK NPI" identifier , issued by the state of ( AR ) . This identifiers is of the category "OTHER".
  • Identifier: 1962401463 . This is a "INDIVIDUAL NPI NUMBER" identifier , issued by the state of ( AR ) . This identifiers is of the category "OTHER".
  • Identifier: 1730109877 . This is a "INDIVIDUAL NPI NUMBER" identifier , issued by the state of ( AR ) . This identifiers is of the category "OTHER".




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