Healthcare Provider Details

I. General information

NPI: 1215005731
Provider Name (Legal Business Name): LITTLE ROCK DERMATOLOGY CLINIC P.A.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/01/2006
Last Update Date: 08/31/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 S UNIVERSITY AVE 301
LITTLE ROCK AR
72205-5302
US

IV. Provider business mailing address

500 S UNIVERSITY AVE 301
LITTLE ROCK AR
72205-5302
US

V. Phone/Fax

Practice location:
  • Phone: 501-664-4161
  • Fax: 501-664-6108
Mailing address:
  • Phone: 501-664-4161
  • Fax: 501-664-6108

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number5C206
License Number StateAR

VIII. Authorized Official

Name: MISS MARION NIXON
Title or Position: OFFICE MANAGER
Credential:
Phone: 501-664-4161