Healthcare Provider Details

I. General information

NPI: 1285735654
Provider Name (Legal Business Name): MARIA THERESA RODRIGUEZ TRAVIS M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: THERESA TRAVIS

II. Dates (important events)

Enumeration Date: 09/26/2006
Last Update Date: 07/15/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5 LORIAN CIR
LITTLE ROCK AR
72212-2662
US

IV. Provider business mailing address

5 LORIAN CIR
LITTLE ROCK AR
72212-2662
US

V. Phone/Fax

Practice location:
  • Phone: 501-912-3953
  • Fax:
Mailing address:
  • Phone: 501-912-3953
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberC6465
License Number StateAR
# 2
Primary TaxonomyN
Taxonomy Code208VP0000X
TaxonomyPain Medicine Physician
License NumberC-6465
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: