Provider Demographics
NPI:1093916256
Name:HUMBARD, STEPHEN (MD)
Entity Type:Individual
Prefix:
First Name:STEPHEN
Middle Name:
Last Name:HUMBARD
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 1:28 RAHLING CIRCLE
Mailing Address - Street 2:SUITE 2
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72223-9187
Mailing Address - Country:US
Mailing Address - Phone:501-448-2510
Mailing Address - Fax:501-448-2514
Practice Address - Street 1:28 RAHLING CIRCLE
Practice Address - Street 2:SUITE 2
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72223-9187
Practice Address - Country:US
Practice Address - Phone:501-448-2510
Practice Address - Fax:501-448-2514
Is Sole Proprietor?:No
Enumeration Date:2007-05-29
Last Update Date:2015-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARE-5932207Q00000X
AR390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR179049001Medicaid