MEDICARE: VON PHOMAKAY DO

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	E0767	AR

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1306833116
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	VON PHOMAKAY DO

Provider Business Mailing Address
First Line	:	PO BOX 402319
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30384-2319
Country	:	US
Telephone Number	:	479-709-7399
Fax Number	:	479-709-7053

Provider Business Practice Location Address
First Line	:	5111 ROGERS AVE
Second Line	:	STE 40M
City	:	FORT SMITH
State	:	AR
Zip	:	72903-2047
Country	:	US
Telephone Number	:	479-709-7440
Fax Number	:	479-709-7441

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

Provider Enumeration Date	:	10/06/2005
Last Update Date	:	08/23/2010

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Directions to “ VON PHOMAKAY DO” Practice Location

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