Healthcare Provider Details

I. General information

NPI: 1275877425
Provider Name (Legal Business Name): JEFFREY L TATE MD PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/11/2012
Last Update Date: 11/26/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5311 VILLAGE PKWY
ROGERS AR
72758-8102
US

IV. Provider business mailing address

5311 VILLAGE PKWY
ROGERS AR
72758-8102
US

V. Phone/Fax

Practice location:
  • Phone: 479-271-6511
  • Fax: 479-271-6518
Mailing address:
  • Phone: 479-271-6511
  • Fax: 479-271-6518

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License NumberN8345
License Number StateAR

VIII. Authorized Official

Name: JEFFREY LEWIS TATE
Title or Position: PRESIDENT
Credential: M.D.
Phone: 479-271-6511