Organization
OZARK DERMATOLOGY CLINIC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
DIANE WILLIAMS (CREDENTIALING MANAGER)
(479) 335-1831
Entity
Organization
Contact information
Practice address
4375 N. VANTAGE DRIVE, SUITE 305, FAYETTEVILLE, AR 72703-4984
(479) 443-5100
(479) 443-5117
Mailing address
4375 N. VANTAGE DRIVE, SUITE 305, FAYETTEVILLE, AR 72703-4984
(479) 443-5100
(479) 443-5117
Taxonomy
Speciality
Code
Description
License number
State
174400000X
Specialist
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
14568002
—
AR
01
—
7897701
AETNA
AR
Enumeration date
11/02/2006
Last updated
02/22/2022
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