Healthcare Provider Details

I. General information

NPI: 1194082057
Provider Name (Legal Business Name): BLAKE ANTHONY WILLIAMS M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/17/2012
Last Update Date: 11/03/2025
Certification Date: 11/03/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

901 SE PLAZA AVE STE 5
BENTONVILLE AR
72712-5473
US

IV. Provider business mailing address

1651 E STEARNS ST STE 110
FAYETTEVILLE AR
72703-6196
US

V. Phone/Fax

Practice location:
  • Phone: 479-876-8550
  • Fax: 479-208-4266
Mailing address:
  • Phone: 479-876-8550
  • Fax: 479-208-4266

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License NumberE-9143
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: