1942209572 NPI number — SUSAN DIANE BLAIR M.D.

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1942209572 NPI number — SUSAN DIANE BLAIR M.D.

Employer Identification Number (EIN):

Provider Organization Name:

Provider Last Name:

BLAIR

Provider First Name:

SUSAN

Provider Middle Name:

DIANE

Provider Name Prefix Text:

Provider Name Suffix Text:

Provider Credential Text:

M.D.

Provider Gender Code:

F

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:

1942209572

Entity Type Code:

Individual

Replacement NPI:

Last Update Date:

10/15/2019

NPI Deactivation Reason Code:

NPI Deactivation Date:

NPI Reactivation Date:

Provider First Line Business Mailing Address:

201 EXECUTIVE CT STE A

Provider Second Line Business Mailing Address:

Provider Business Mailing Address City Name:

LITTLE ROCK

Provider Business Mailing Address State Name:

AR

Provider Business Mailing Address Postal Code:

72205-4536

Provider Business Mailing Address Country Code:

US

Provider Business Mailing Address Telephone Number:

501-224-5658

Provider Business Mailing Address Fax Number:

501-223-8656

Provider First Line Business Practice Location Address:

4200 N RODNEY PARHAM RD STE 101

Provider Second Line Business Practice Location Address:

Provider Business Practice Location Address City Name:

LITTLE ROCK

Provider Business Practice Location Address State Name:

AR

Provider Business Practice Location Address Postal Code:

72212-2458

Provider Business Practice Location Address Country Code:

US

Provider Business Practice Location Address Telephone Number:

501-224-5658

Provider Business Practice Location Address Fax Number:

501-224-8114

Provider Enumeration Date:

07/15/2005

Authorized Official Last Name:

Authorized Official First Name:

Authorized Official Middle Name:

Authorized Official Title or Position:

Authorized Official Telephone Number:

• Taxonomy code: 207W00000X , with the licence number:  C7661 , registered in the state of AR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

• Identifier: 08-20033 . This is a "UNITED HEALTHCARE" identifier , issued by the state of ( AR ) . This identifiers is of the category "OTHER".
• Identifier: 180030604 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( AR ) . This identifiers is of the category "OTHER".
• Identifier: 5B955 . This is a "BLUE CROSS PAY TO PROVIDE" identifier , issued by the state of ( AR ) . This identifiers is of the category "OTHER".
• Identifier: 4514242 . This is a "AETNA" identifier , issued by the state of ( AR ) . This identifiers is of the category "OTHER".
• Identifier: 11825 . This is a "COORDINATED VISION CARE" identifier , issued by the state of ( AR ) . This identifiers is of the category "OTHER".
• Identifier: 13629000000 . This is a "QUALCHOICE" identifier , issued by the state of ( AR ) . This identifiers is of the category "OTHER".
• Identifier: 54157 . This is a "BLUE CROSS OF AR" identifier , issued by the state of ( AR ) . This identifiers is of the category "OTHER".
• Identifier: CJ3133 . This is a "RR MEDICARE GROUP #" identifier , issued by the state of ( AR ) . This identifiers is of the category "OTHER".
• Identifier: 2454752 . This is a "CIGNA" identifier , issued by the state of ( AR ) . This identifiers is of the category "OTHER".
• Identifier: 125599001 , issued by the state of ( AR ) . This identifiers is of the category "MEDICAID".
• Identifier: C7661 . This is a "STATE MEDICAL BOARD" identifier , issued by the state of ( AR ) . This identifiers is of the category "OTHER".