Healthcare Provider Details

I. General information

NPI: 1437133352
Provider Name (Legal Business Name): LESLIE C LOCKRIDGE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/05/2005
Last Update Date: 04/01/2025
Certification Date: 04/01/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

639 HOSPITAL DR
MOUNTAIN HOME AR
72653-2914
US

IV. Provider business mailing address

3901 PARKWAY CIR
SPRINGDALE AR
72762-6362
US

V. Phone/Fax

Practice location:
  • Phone: 479-587-1700
  • Fax: 479-587-1366
Mailing address:
  • Phone: 479-587-1700
  • Fax: 479-587-1366

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberMD10934
License Number StateRI
# 2
Primary TaxonomyN
Taxonomy Code207RH0003X
TaxonomyHematology & Oncology Physician
License NumberMD10934
License Number StateRI
# 3
Primary TaxonomyN
Taxonomy Code207RH0003X
TaxonomyHematology & Oncology Physician
License Number0420011226
License Number StateVT
# 4
Primary TaxonomyN
Taxonomy Code207RH0003X
TaxonomyHematology & Oncology Physician
License Number217751
License Number StateMA
# 5
Primary TaxonomyN
Taxonomy Code207RH0003X
TaxonomyHematology & Oncology Physician
License Number042-0011226
License Number StateVT
# 6
Primary TaxonomyY
Taxonomy Code207RH0000X
TaxonomyHematology (Internal Medicine) Physician
License NumberE18889
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: