Healthcare Provider Details

I. General information

NPI: 1942209572
Provider Name (Legal Business Name): SUSAN DIANE BLAIR M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/15/2005
Last Update Date: 04/15/2025
Certification Date: 04/15/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4200 N RODNEY PARHAM RD STE 101
LITTLE ROCK AR
72212-2458
US

IV. Provider business mailing address

201 EXECUTIVE CT STE A
LITTLE ROCK AR
72205-4536
US

V. Phone/Fax

Practice location:
  • Phone: 501-224-5658
  • Fax: 501-224-8114
Mailing address:
  • Phone: 501-224-5658
  • Fax: 501-223-8656

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License NumberC7661
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: