MEDICARE: GEORGE RYAN DECLERK M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician	E5450	AR

General Provider Information

NPI Number	:	1205037611
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	GEORGE RYAN DECLERK M.D.

Provider Business Mailing Address
First Line	:	2603 W PLEASANT GROVE RD
Second Line	:	SUITE 109
City	:	ROGERS
State	:	AR
Zip	:	72758-5804
Country	:	US
Telephone Number	:	479-636-4138
Fax Number	:	479-636-4140

Provider Business Practice Location Address
First Line	:	2603 W PLEASANT GROVE RD
Second Line	:	SUITE 109
City	:	ROGERS
State	:	AR
Zip	:	72758-5804
Country	:	US
Telephone Number	:	479-636-4138
Fax Number	:	479-636-4140

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/31/2007
Last Update Date	:	09/09/2020

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