Provider Demographics
NPI:1093729246
Name:MULLIS, RONALD J (MD)
Entity Type:Individual
Prefix:DR
First Name:RONALD
Middle Name:J
Last Name:MULLIS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:JAY
Other - Middle Name:
Other - Last Name:MULLIS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:3 E APPLEBY RD STE 401
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72703-3163
Mailing Address - Country:US
Mailing Address - Phone:479-404-2500
Mailing Address - Fax:479-404-2501
Practice Address - Street 1:3 E APPLEBY RD STE 401
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:AR
Practice Address - Zip Code:72703-3163
Practice Address - Country:US
Practice Address - Phone:479-404-2500
Practice Address - Fax:479-404-2501
Is Sole Proprietor?:No
Enumeration Date:2006-07-27
Last Update Date:2023-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARC7126208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR113060001Medicaid
AR247267OtherHEALTHLINK
AR4347758OtherAETNA INDIVIDUAL #
MO203560800Medicaid
AR12445000000OtherQUALCHOICE
OK100077770AMedicaid
MO203560800Medicaid
AR4347758OtherAETNA INDIVIDUAL #