Healthcare Provider Details

I. General information

NPI: 1578982526
Provider Name (Legal Business Name): JOHN CLIFTON FAIRCLOTH D.O
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/07/2014
Last Update Date: 03/04/2025
Certification Date: 03/04/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1001 TOWSON AVE
FORT SMITH AR
72901-4921
US

IV. Provider business mailing address

PO BOX 1983
FORT SMITH AR
72902-1983
US

V. Phone/Fax

Practice location:
  • Phone: 479-441-4000
  • Fax: 479-441-3779
Mailing address:
  • Phone: 479-452-9416
  • Fax: 479-242-1990

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberOS20506
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberE12135
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: