Healthcare Provider Details

I. General information

NPI: 1285263913
Provider Name (Legal Business Name): MATHEW JOSIAH BAKER RD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/04/2020
Last Update Date: 09/28/2026
Certification Date: 09/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3901 PARKWAY CIR
SPRINGDALE AR
72762-6362
US

IV. Provider business mailing address

3901 PARKWAY CIR
SPRINGDALE AR
72762-6362
US

V. Phone/Fax

Practice location:
  • Phone: 479-587-1700
  • Fax: 479-587-1366
Mailing address:
  • Phone: 479-587-1700
  • Fax: 479-587-1366

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: