1962864694 NPI number — DR. PHILLIP G DOERNER III D.O.

Table of content: DR. PHILLIP G DOERNER III D.O. (NPI 1962864694)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1962864694 NPI number — DR. PHILLIP G DOERNER III D.O.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DOERNER
Provider First Name:
PHILLIP
Provider Middle Name:
G
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
III
Provider Credential Text:
D.O.
Provider Gender Code:
M

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:
1962864694
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/19/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 550
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LOWELL
Provider Business Mailing Address State Name:
AR
Provider Business Mailing Address Postal Code:
72745-0550
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
479-463-7775
Provider Business Mailing Address Fax Number:
479-463-7187

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3215 N NORTHHILLS BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FAYETTEVILLE
Provider Business Practice Location Address State Name:
AR
Provider Business Practice Location Address Postal Code:
72703-4424
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
479-463-7102
Provider Business Practice Location Address Fax Number:
479-463-7864
Provider Enumeration Date:
03/22/2016

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 390200000X , registered in the state of AR ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208M00000X , with the licence number: E-11424 , 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)





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