Healthcare Provider Details

I. General information

NPI: 1013301936
Provider Name (Legal Business Name): CARL PRESTON MCCORMACK MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/28/2015
Last Update Date: 11/29/2022
Certification Date: 11/29/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1001 N UNIVERSITY AVE STE 150
LITTLE ROCK AR
72207-6369
US

IV. Provider business mailing address

1001 N UNIVERSITY AVE STE 150
LITTLE ROCK AR
72207-6369
US

V. Phone/Fax

Practice location:
  • Phone: 501-361-3249
  • Fax:
Mailing address:
  • Phone: 501-361-3249
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberE-12101
License Number StateAR
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberE-12101
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: