Healthcare Provider Details

I. General information

NPI: 1316478845
Provider Name (Legal Business Name): CARLY ROARK M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/26/2017
Last Update Date: 06/13/2020
Certification Date: 06/13/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

625 UNITED DR STE 360
CONWAY AR
72032-7831
US

IV. Provider business mailing address

625 UNITED DR STE 360
CONWAY AR
72032-7831
US

V. Phone/Fax

Practice location:
  • Phone: 501-358-6892
  • Fax:
Mailing address:
  • Phone: 501-358-6892
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberE-13303
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: