Healthcare Provider Details

I. General information

NPI: 1255391389
Provider Name (Legal Business Name): DOUGLAS KERIN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/24/2006
Last Update Date: 01/11/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3301 W MAIN PL
RUSSELLVILLE AR
72801-2334
US

IV. Provider business mailing address

PO BOX 9178
RUSSELLVILLE AR
72811-9178
US

V. Phone/Fax

Practice location:
  • Phone: 479-968-7930
  • Fax: 479-968-1673
Mailing address:
  • Phone: 479-968-7930
  • Fax: 479-968-4331

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberN7605
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: