Healthcare Provider Details

I. General information

NPI: 1295722668
Provider Name (Legal Business Name): RALPH MARTIN MAXWELL DO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/30/2005
Last Update Date: 12/20/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

811 HIGHWAY 65 S
DUMAS AR
71639-3006
US

IV. Provider business mailing address

811 HIGHWAY 65 S PO BOX 830
DUMAS AR
71639-3006
US

V. Phone/Fax

Practice location:
  • Phone: 870-382-8261
  • Fax: 870-382-8140
Mailing address:
  • Phone: 870-382-8261
  • Fax: 870-382-8140

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number00356
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: