Healthcare Provider Details

I. General information

NPI: 1205290046
Provider Name (Legal Business Name): SIGNE L. REBOLLEDO M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: SIGNE K. LARSON

II. Dates (important events)

Enumeration Date: 04/07/2016
Last Update Date: 08/12/2024
Certification Date: 08/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3344 N FUTRALL DR
FAYETTEVILLE AR
72703-4057
US

IV. Provider business mailing address

PO BOX 1523
FAYETTEVILLE AR
72702-1523
US

V. Phone/Fax

Practice location:
  • Phone: 479-521-8200
  • Fax: 479-582-7329
Mailing address:
  • Phone: 479-571-6038
  • Fax: 479-582-0222

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085N0700X
TaxonomyNeuroradiology Physician
License Number12229853-1205
License Number StateUT
# 2
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberE-11434
License Number StateAR
# 3
Primary TaxonomyY
Taxonomy Code2085N0700X
TaxonomyNeuroradiology Physician
License NumberE-11434
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: