Healthcare Provider Details

I. General information

NPI: 1407815467
Provider Name (Legal Business Name): FREDRICK ALLAN MARTIN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/20/2006
Last Update Date: 09/22/2023
Certification Date: 09/22/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

813 FOUNDERS PARK DR E STE 107
SPRINGDALE AR
72762-6321
US

IV. Provider business mailing address

813 FOUNDERS PARK DR E STE 107
SPRINGDALE AR
72762-6321
US

V. Phone/Fax

Practice location:
  • Phone: 479-463-6600
  • Fax: 479-463-6624
Mailing address:
  • Phone: 479-463-6600
  • Fax: 479-463-6624

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberC-6262
License Number StateAR
# 2
Primary TaxonomyY
Taxonomy Code207QG0300X
TaxonomyGeriatric Medicine (Family Medicine) Physician
License NumberC6262
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: