Healthcare Provider Details

I. General information

NPI: 1003073628
Provider Name (Legal Business Name): AMY L COLLINSWORTH MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/21/2008
Last Update Date: 03/09/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4850 NORTHSHORE LN
NORTH LITTLE ROCK AR
72118
US

IV. Provider business mailing address

4850 NORTHSHORE LN
NORTH LITTLE ROCK AR
72118
US

V. Phone/Fax

Practice location:
  • Phone: 501-225-1400
  • Fax: 501-225-1401
Mailing address:
  • Phone: 501-225-1400
  • Fax: 501-225-1401

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207ZP0102X
TaxonomyAnatomic Pathology & Clinical Pathology Physician
License NumberMD.202964
License Number StateLA
# 2
Primary TaxonomyN
Taxonomy Code207ZP0102X
TaxonomyAnatomic Pathology & Clinical Pathology Physician
License Number2018-00213
License Number StateNC
# 3
Primary TaxonomyN
Taxonomy Code207ZP0102X
TaxonomyAnatomic Pathology & Clinical Pathology Physician
License NumberME113275
License Number StateFL
# 4
Primary TaxonomyY
Taxonomy Code207ZP0102X
TaxonomyAnatomic Pathology & Clinical Pathology Physician
License NumberE-11085
License Number StateAR
# 5
Primary TaxonomyN
Taxonomy Code207ZP0102X
TaxonomyAnatomic Pathology & Clinical Pathology Physician
License Number79531
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: