Healthcare Provider Details

I. General information

NPI: 1275584575
Provider Name (Legal Business Name): TWIN LAKES MEDICAL SPECIALISTS, PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/12/2006
Last Update Date: 11/25/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

628 HOSPITAL DRIVE GROUND FLOOR SUITE A
MOUNTAIN HOME AR
72653-2953
US

IV. Provider business mailing address

628 HOSPITAL DRIVE GROUND FLOOR SUITE A
MOUNTAIN HOME AR
72653-2953
US

V. Phone/Fax

Practice location:
  • Phone: 870-425-4402
  • Fax: 870-425-6811
Mailing address:
  • Phone: 870-425-4402
  • Fax: 870-424-3089

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2085R0001X
TaxonomyRadiation Oncology Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code207RX0202X
TaxonomyMedical Oncology Physician
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number State

VIII. Authorized Official

Name: WILLIAM S DYER
Title or Position: SECRETARY/OWNER
Credential: M.D.
Phone: 870-425-4402