=====================================================
General NPI Number Information
=====================================================
NPI Number | 1306808829
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LUIS M CARRASCO MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/03/2006
-----------------------------------------------------
Last Update Date | 09/23/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1233 WEST POPLAR
-----------------------------------------------------
City | ROGERS
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 72756-4249
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 479-636-9235
-----------------------------------------------------
Fax | 479-631-0374
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 614 E EMMA AVE STE 300
-----------------------------------------------------
City | SPRINGDALE
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 72764-4469
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 479-751-7417
-----------------------------------------------------
Fax | 479-751-4898
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208000000X
-----------------------------------------------------
Taxonomy Name | Pediatrics Physician
-----------------------------------------------------
License Number | 33347
-----------------------------------------------------
License Number State | KY
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 208000000X
-----------------------------------------------------
Taxonomy Name | Pediatrics Physician
-----------------------------------------------------
License Number | E-9613
-----------------------------------------------------
License Number State | AR
-----------------------------------------------------