Healthcare Provider Details

I. General information

NPI: 1376589754
Provider Name (Legal Business Name): CHRISTIAN G BLANKERS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/22/2006
Last Update Date: 12/15/2021
Certification Date: 12/15/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

775 E DOUGLAS ST
PRAIRIE GROVE AR
72753
US

IV. Provider business mailing address

PO BOX 1523
FAYETTEVILLE AR
72702-1523
US

V. Phone/Fax

Practice location:
  • Phone: 479-846-5005
  • Fax: 479-846-5056
Mailing address:
  • Phone: 479-571-6038
  • Fax: 479-582-0222

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberE-2615
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: