Healthcare Provider Details

I. General information

NPI: 1487655247
Provider Name (Legal Business Name): THOMAS ROBERT MOFFETT JR. MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/02/2005
Last Update Date: 10/17/2024
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11300 N RODNEY PARHAM RD SUITE 210
LITTLE ROCK AR
72212-4153
US

IV. Provider business mailing address

11300 N RODNEY PARHAM RD SUITE 210
LITTLE ROCK AR
72212-4153
US

V. Phone/Fax

Practice location:
  • Phone: 501-663-4100
  • Fax: 501-663-4145
Mailing address:
  • Phone: 501-663-4100
  • Fax: 501-663-4145

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License NumberR4045
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: