Individual
SUH N NIBA
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
M.D.
Contact information
Practice address
14 GOTHIC RIDGE RD, VAN BUREN, AR 72956-6565
(479) 474-1100
(479) 474-0069
Mailing address
14 GOTHIC RIDGE RD, VAN BUREN, AR 72956-6565
(479) 474-1100
(479) 474-0069
Taxonomy
Speciality
Code
Description
License number
State
207Q00000X
Family Medicine Physician
Primary
E3975
AR
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
154343001
—
AR
Enumeration date
05/24/2006
Last updated
02/15/2020
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