1689035263 NPI number — DODD FAMILY PRACTICE, PLLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1689035263 NPI number — DODD FAMILY PRACTICE, PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DODD FAMILY PRACTICE, PLLC
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:
1689035263
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/11/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1280
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CLINTON
Provider Business Mailing Address State Name:
AR
Provider Business Mailing Address Postal Code:
72031-1280
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
501-745-2713
Provider Business Mailing Address Fax Number:
501-745-2714

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
451 INGRAM ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CLINTON
Provider Business Practice Location Address State Name:
AR
Provider Business Practice Location Address Postal Code:
72031-7078
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
501-745-2713
Provider Business Practice Location Address Fax Number:
501-745-2714
Provider Enumeration Date:
03/10/2016

Additional Information

Authorized Official

Authorized Official Last Name:
DODD
Authorized Official First Name:
ANGELA
Authorized Official Middle Name:
GAIL
Authorized Official Title or Position:
APRN
Authorized Official Telephone Number:
501-745-2713

Provider Taxonomy Codes

  • Taxonomy code: 363LF0000X , with the licence number:  A003662 , 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: 192317758 , issued by the state of ( AR ) . This identifiers is of the category "MEDICAID".




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