Provider Demographics
NPI:1073687505
Name:DIAMOND, KEVIN M (MD)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:M
Last Name:DIAMOND
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 839
Mailing Address - Street 2:
Mailing Address - City:WALNUT RIDGE
Mailing Address - State:AR
Mailing Address - Zip Code:72476-0839
Mailing Address - Country:US
Mailing Address - Phone:870-886-3211
Mailing Address - Fax:870-886-3616
Practice Address - Street 1:1309 W MAIN ST
Practice Address - Street 2:
Practice Address - City:WALNUT RIDGE
Practice Address - State:AR
Practice Address - Zip Code:72476-1430
Practice Address - Country:US
Practice Address - Phone:870-886-3211
Practice Address - Fax:870-886-9027
Is Sole Proprietor?:No
Enumeration Date:2006-11-17
Last Update Date:2023-01-10
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
ARE0535207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR5J928OtherBLUE CROSS BLUE SHIELD
AR128088001Medicaid
AR128088001Medicaid
AR5J928OtherBLUE CROSS BLUE SHIELD