Healthcare Provider Details

I. General information

NPI: 1578550851
Provider Name (Legal Business Name): MARK R STOREY MD
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 10/03/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

CARTI-MARKHAM & UNIVERSITY #4 ST. VINCENT CIRCLE
LITTLE ROCK AR
72205
US

IV. Provider business mailing address

PO BOX 56409
LITTLE ROCK AR
72215-6409
US

V. Phone/Fax

Practice location:
  • Phone: 501-296-3273
  • Fax: 501-664-8721
Mailing address:
  • Phone: 501-296-3273
  • Fax: 501-664-8721

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0001X
TaxonomyRadiation Oncology Physician
License NumberE2669
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: