Healthcare Provider Details

I. General information

NPI: 1427236926
Provider Name (Legal Business Name): DICKSON STREET CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/06/2008
Last Update Date: 02/06/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

102 W DICKSON ST
FAYETTEVILLE AR
72701-5219
US

IV. Provider business mailing address

102 W DICKSON ST
FAYETTEVILLE AR
72701-5219
US

V. Phone/Fax

Practice location:
  • Phone: 479-521-1114
  • Fax: 479-521-2540
Mailing address:
  • Phone: 479-521-1114
  • Fax: 479-521-2540

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QA0505X
TaxonomyAdult Medicine Physician
License NumberC4954
License Number StateAR

VIII. Authorized Official

Name: DR. CARL R MAGNESS
Title or Position: OWNER/PHYSICIAN
Credential: MD
Phone: 479-521-1114