Healthcare Provider Details

I. General information

NPI: 1093729246
Provider Name (Legal Business Name): RONALD J MULLIS M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: JAY MULLIS

II. Dates (important events)

Enumeration Date: 07/27/2006
Last Update Date: 06/06/2023
Certification Date: 06/06/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3 E APPLEBY RD STE 401
FAYETTEVILLE AR
72703-3163
US

IV. Provider business mailing address

3 E APPLEBY RD STE 401
FAYETTEVILLE AR
72703-3163
US

V. Phone/Fax

Practice location:
  • Phone: 479-404-2500
  • Fax: 479-404-2501
Mailing address:
  • Phone: 479-404-2500
  • Fax: 479-404-2501

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberC7126
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: