Healthcare Provider Details

I. General information

NPI: 1649447806
Provider Name (Legal Business Name): LANDON D HUMPHREY
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/15/2008
Last Update Date: 05/12/2026
Certification Date: 05/12/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1500 MUSEUM RD
CONWAY AR
72032-4785
US

IV. Provider business mailing address

PO BOX 497
AUGUSTA AR
72006-0497
US

V. Phone/Fax

Practice location:
  • Phone: 501-932-9010
  • Fax: 501-932-0020
Mailing address:
  • Phone: 870-347-2534
  • Fax: 870-347-1235

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberE-9315
License Number StateAR
# 2
Primary TaxonomyN
Taxonomy Code2083P0011X
TaxonomyUndersea and Hyperbaric Medicine (Preventive Medicine) Physician
License NumberE-9315
License Number StateAR
# 3
Primary TaxonomyN
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License NumberE-9315
License Number StateAR
# 4
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: