Healthcare Provider Details

I. General information

NPI: 1508851320
Provider Name (Legal Business Name): MOISES A MENENDEZ MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/19/2005
Last Update Date: 06/18/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 HOSPTIAL DRIVE
MAGNOLIA AR
71753
US

IV. Provider business mailing address

PO BOX 629
MAGNOLIA AR
71754
US

V. Phone/Fax

Practice location:
  • Phone: 870-235-3600
  • Fax:
Mailing address:
  • Phone: 870-235-3600
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberR2525
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: