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General NPI Number Information
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NPI Number | 1902865579
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Entity Type | Organization
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Legal Business Name | OAK PARK MEDICAL C,LINIC, P.A.
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Dates
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Enumeration Date | 03/21/2006
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 1301 WHITE DR
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City | BATESVILLE
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State | AR
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Zip | 72501-9467
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Country | US
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Telephone | 870-793-6887
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Fax | 870-793-8085
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Provider Business Mailing Address
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Address Line | PO BOX 2335
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City | BATESVILLE
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State | AR
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Zip | 72503-2335
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Country | US
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Telephone | 870-793-6887
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Fax | 870-793-8085
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Authorized Official
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Title or Position | CEO
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Name | DR. LACKEY GENE MOODY
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Credential | M.D.
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Telephone | 870-793-9887
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | C-4126
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License Number State | AR
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