Provider Demographics
NPI:1063477479
Name:OLDHAM, MICHAEL C (DC)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:C
Last Name:OLDHAM
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:827 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:BLYTHEVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72315-2521
Mailing Address - Country:US
Mailing Address - Phone:870-763-8155
Mailing Address - Fax:870-838-1589
Practice Address - Street 1:827 E MAIN ST
Practice Address - Street 2:
Practice Address - City:BLYTHEVILLE
Practice Address - State:AR
Practice Address - Zip Code:72315-2521
Practice Address - Country:US
Practice Address - Phone:870-763-8155
Practice Address - Fax:870-838-1589
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR1542111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR1542OtherARKANSAS LICENSE #
AR5C699Medicare ID - Type UnspecifiedOLDHAM CHIROPRACTIC
AR5U745Medicare ID - Type Unspecified