Healthcare Provider Details

I. General information

NPI: 1154983237
Provider Name (Legal Business Name): BLAINE MICHAEL WINTERTON DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/28/2019
Last Update Date: 07/30/2025
Certification Date: 07/30/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2713 S 74TH ST STE 301
FORT SMITH AR
72903-5155
US

IV. Provider business mailing address

PO BOX 776084
CHICAGO IL
60677-6084
US

V. Phone/Fax

Practice location:
  • Phone: 479-314-4620
  • Fax: 479-314-4630
Mailing address:
  • Phone: 479-314-4620
  • Fax: 479-314-4630

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number2019021801
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License Number2022021013
License Number StateMO
# 3
Primary TaxonomyY
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License NumberE-19090
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: