Healthcare Provider Details

I. General information

NPI: 1295983237
Provider Name (Legal Business Name): DE QUEEN PEDIATRICS INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/03/2008
Last Update Date: 04/24/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1357 W COLLIN RAYE DR
DE QUEEN AR
71832-2946
US

IV. Provider business mailing address

1357 W COLLIN RAYE DR
DE QUEEN AR
71832-2946
US

V. Phone/Fax

Practice location:
  • Phone: 870-642-4364
  • Fax:
Mailing address:
  • Phone: 870-642-4364
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License NumberE-2169
License Number StateAR
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberE-2169
License Number StateAR

VIII. Authorized Official

Name: TERRI A DEVLIN
Title or Position: OWNER/PHYSICIAN
Credential: M.D.
Phone: 870-642-4364