Healthcare Provider Details

I. General information

NPI: 1548345606
Provider Name (Legal Business Name): CARL ROBERT MAGNESS M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

Provider Other Name: C.R. MAGNESS M.D.

II. Dates (important events)

Enumeration Date: 10/26/2006
Last Update Date: 05/15/2015
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:
Title or Position:
Credential:
Phone: