Healthcare Provider Details

I. General information

NPI: 1356304091
Provider Name (Legal Business Name): SUSAN M AVERITT MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/11/2006
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5501 WILLOW CREEK DR. STE 203
SPRINGDALE AR
72762
US

IV. Provider business mailing address

5501 WILLOW CREEK DR. STE 203
SPRINGDALE AR
72762
US

V. Phone/Fax

Practice location:
  • Phone: 479-575-9359
  • Fax: 479-575-9415
Mailing address:
  • Phone: 479-757-8099
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number23620
License Number StateOK
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberE2459
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: