Healthcare Provider Details

I. General information

NPI: 1306475470
Provider Name (Legal Business Name): AMIR AMIDI MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/02/2020
Last Update Date: 11/15/2023
Certification Date: 11/12/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3017 S 70TH ST STE G
FORT SMITH AR
72903-5000
US

IV. Provider business mailing address

3017 S 70TH ST STE FGH
FORT SMITH AR
72903-5049
US

V. Phone/Fax

Practice location:
  • Phone: 479-802-4068
  • Fax:
Mailing address:
  • Phone: 479-802-4068
  • Fax: 479-315-5914

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP3300X
TaxonomyPain Clinic/Center
License NumberE-16590
License Number StateAR
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberE-16590
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: