Healthcare Provider Details

I. General information

NPI: 1902038375
Provider Name (Legal Business Name): MARJORIE ANTENOR EDWARDS M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/18/2009
Last Update Date: 04/20/2021
Certification Date: 04/20/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1615 W PERSIMMON ST
ROGERS AR
72756-3359
US

IV. Provider business mailing address

1615 W PERSIMMON ST
ROGERS AR
72756-3359
US

V. Phone/Fax

Practice location:
  • Phone: 479-636-7192
  • Fax: 479-631-8212
Mailing address:
  • Phone: 479-636-7192
  • Fax: 479-631-8212

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number2014015316
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberE-7010
License Number StateAR
# 3
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberE-7010
License Number StateAR
# 4
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number2014015316
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: