=====================================================
General NPI Number Information
=====================================================
NPI Number | 1407815467
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | FREDRICK ALLAN MARTIN M.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/20/2006
-----------------------------------------------------
Last Update Date | 09/22/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 813 FOUNDERS PARK DR E STE 107
-----------------------------------------------------
City | SPRINGDALE
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 72762-6321
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 479-463-6600
-----------------------------------------------------
Fax | 479-463-6624
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 813 FOUNDERS PARK DR E STE 107
-----------------------------------------------------
City | SPRINGDALE
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 72762-6321
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 479-463-6600
-----------------------------------------------------
Fax | 479-463-6624
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | C-6262
-----------------------------------------------------
License Number State | AR
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207QG0300X
-----------------------------------------------------
Taxonomy Name | Geriatric Medicine (Family Medicine) Physician
-----------------------------------------------------
License Number | C6262
-----------------------------------------------------
License Number State | AR
-----------------------------------------------------