Healthcare Provider Details

I. General information

NPI: 1235130444
Provider Name (Legal Business Name): CLINTON AVERY NETHERLAND M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/10/2005
Last Update Date: 03/07/2023
Certification Date: 03/30/2020
Deactivation Date: 03/23/2006
Reactivation Date: 03/28/2006

III. Provider practice location address

1400 PERSHING HWY
SMACKOVER AR
71762-2300
US

IV. Provider business mailing address

1400 PERSHING HWY
SMACKOVER AR
71762-2300
US

V. Phone/Fax

Practice location:
  • Phone: 870-725-3471
  • Fax: 870-725-3471
Mailing address:
  • Phone: 870-725-3471
  • Fax: 870-725-3041

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberE1883
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: