Healthcare Provider Details

I. General information

NPI: 1306808829
Provider Name (Legal Business Name): LUIS M CARRASCO MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/03/2006
Last Update Date: 09/23/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1233 WEST POPLAR
ROGERS AR
72756-4249
US

IV. Provider business mailing address

614 E EMMA AVE STE 300
SPRINGDALE AR
72764-4469
US

V. Phone/Fax

Practice location:
  • Phone: 479-636-9235
  • Fax: 479-631-0374
Mailing address:
  • Phone: 479-751-7417
  • Fax: 479-751-4898

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number33347
License Number StateKY
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberE-9613
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: