Healthcare Provider Details

I. General information

NPI: 1710974548
Provider Name (Legal Business Name): DANA P RABIDEAU MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/06/2005
Last Update Date: 08/23/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1500 DODSON AVE STE 280
FORT SMITH AR
72901-5182
US

IV. Provider business mailing address

PO BOX 402319
ATLANTA GA
30384-2319
US

V. Phone/Fax

Practice location:
  • Phone: 479-709-7480
  • Fax: 479-709-7479
Mailing address:
  • Phone: 479-709-7399
  • Fax: 479-709-7053

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License NumberN6097
License Number StateAR
# 2
Primary TaxonomyN
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License Number15018
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: