Provider Demographics
NPI:1043312812
Name:CALLAHAN, DOUGLAS G (MD)
Entity Type:Individual
Prefix:
First Name:DOUGLAS
Middle Name:G
Last Name:CALLAHAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:350 SALEM ROAD
Mailing Address - Street 2:STE 1
Mailing Address - City:CONWAY
Mailing Address - State:AR
Mailing Address - Zip Code:72034
Mailing Address - Country:US
Mailing Address - Phone:501-336-8300
Mailing Address - Fax:501-329-3572
Practice Address - Street 1:350 SALEM ROAD
Practice Address - Street 2:STE 1
Practice Address - City:CONWAY
Practice Address - State:AR
Practice Address - Zip Code:72034
Practice Address - Country:US
Practice Address - Phone:501-336-8300
Practice Address - Fax:501-329-3572
Is Sole Proprietor?:No
Enumeration Date:2006-09-02
Last Update Date:2011-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARC59602084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR111165001Medicaid
D79371Medicare UPIN
AR111165001Medicaid