Healthcare Provider Details

I. General information

NPI: 1124228382
Provider Name (Legal Business Name): CAROLYN R REEVES D.O.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/24/2007
Last Update Date: 07/07/2022
Certification Date: 07/07/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1415 E CENTERTON BLVD
CENTERTON AR
72719-7050
US

IV. Provider business mailing address

1415 E CENTERON BLVD
CENTERON AR
72719
US

V. Phone/Fax

Practice location:
  • Phone: 479-224-1565
  • Fax: 844-758-8644
Mailing address:
  • Phone: 479-224-1565
  • Fax: 844-758-8644

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number2006018887
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code207RH0002X
TaxonomyHospice and Palliative Medicine (Internal Medicine) Physician
License NumberE6133
License Number StateAR
# 3
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberE6133
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: