Healthcare Provider Details

I. General information

NPI: 1649210584
Provider Name (Legal Business Name): OZARK ORTHOPAEDICS, P.A.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/08/2006
Last Update Date: 04/27/2023
Certification Date: 04/19/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3317 N WIMBERLY DR
FAYETTEVILLE AR
72703-4056
US

IV. Provider business mailing address

PO BOX 1608
FAYETTEVILLE AR
72702
US

V. Phone/Fax

Practice location:
  • Phone: 479-521-2752
  • Fax: 479-521-4603
Mailing address:
  • Phone: 479-521-2752
  • Fax: 479-444-6942

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License NumberMC-0077
License Number StateAR
# 2
Primary TaxonomyN
Taxonomy Code207XS0106X
TaxonomyOrthopaedic Hand Surgery Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code261QU0200X
TaxonomyUrgent Care Clinic/Center
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State

VIII. Authorized Official

Name: TRACY DAVENPORT
Title or Position: CHIEF OPERATING OFFICER
Credential:
Phone: 479-587-3149