Healthcare Provider Details

I. General information

NPI: 1487004990
Provider Name (Legal Business Name): MATEO GUARDERAS RIBADENEIRA M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/15/2016
Last Update Date: 10/16/2024
Certification Date: 10/16/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 SKYLINE DR
RUSSELLVILLE AR
72801-3395
US

IV. Provider business mailing address

101 SKYLINE DR
RUSSELLVILLE AR
72801-3395
US

V. Phone/Fax

Practice location:
  • Phone: 479-968-2345
  • Fax: 479-890-7180
Mailing address:
  • Phone: 799-682-3454
  • Fax: 479-890-7180

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberE-15224
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: