Healthcare Provider Details

I. General information

NPI: 1366490997
Provider Name (Legal Business Name): NORTHWEST DERMATOLOGY CLINIC, P.A.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/05/2006
Last Update Date: 01/06/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5100 S THOMPSON ST # 212
SPRINGDALE AR
72764-6933
US

IV. Provider business mailing address

5100 S THOMPSON ST # 212
SPRINGDALE AR
72764-6933
US

V. Phone/Fax

Practice location:
  • Phone: 479-750-7200
  • Fax: 479-750-7202
Mailing address:
  • Phone: 479-750-7200
  • Fax: 479-750-7202

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License NumberMC1781
License Number StateAR
# 2
Primary TaxonomyN
Taxonomy Code207ND0101X
TaxonomyMOHS-Micrographic Surgery Physician
License NumberMC1781
License Number StateAR
# 3
Primary TaxonomyN
Taxonomy Code207NS0135X
TaxonomyProcedural Dermatology Physician
License NumberMC1781
License Number StateAR
# 4
Primary TaxonomyY
Taxonomy Code207ND0900X
TaxonomyDermatopathology Physician
License NumberMC1781
License Number StateAR

VIII. Authorized Official

Name: JAMES R WHARTON
Title or Position: PRESIDENT
Credential: M.D.
Phone: 479-750-7200