Healthcare Provider Details

I. General information

NPI: 1366354938
Provider Name (Legal Business Name): DECLERK FAMILY MEDICINE, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/18/2026
Last Update Date: 09/18/2026
Certification Date: 09/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4305 S PLEASANT CROSSING BLVD STE 103
ROGERS AR
72758-1347
US

IV. Provider business mailing address

2261 N CENTER ST
GENTRY AR
72734-6022
US

V. Phone/Fax

Practice location:
  • Phone: 479-302-1020
  • Fax:
Mailing address:
  • Phone: 479-422-3647
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: GEORGE RYAN DECLERK
Title or Position: MANAGER
Credential:
Phone: 479-422-3647