Provider Demographics
NPI:1003802828
Name:CONOVER, RANDY (DO)
Entity Type:Individual
Prefix:
First Name:RANDY
Middle Name:
Last Name:CONOVER
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 34
Mailing Address - Street 2:
Mailing Address - City:CENTERTON
Mailing Address - State:AR
Mailing Address - Zip Code:72719-0034
Mailing Address - Country:US
Mailing Address - Phone:479-795-0426
Mailing Address - Fax:479-795-0425
Practice Address - Street 1:101 SUN MEADOW DR
Practice Address - Street 2:
Practice Address - City:CENTERTON
Practice Address - State:AR
Practice Address - Zip Code:72719-9610
Practice Address - Country:US
Practice Address - Phone:479-795-0426
Practice Address - Fax:479-795-0425
Is Sole Proprietor?:No
Enumeration Date:2005-09-27
Last Update Date:2020-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARE2837207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR143769003Medicaid
AR5L862Medicare ID - Type Unspecified
ARH24035Medicare UPIN