Provider Demographics
NPI:1114450822
Name:MANTOOTH, RYAN DAVID (MD)
Entity Type:Individual
Prefix:
First Name:RYAN
Middle Name:DAVID
Last Name:MANTOOTH
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:PO BOX 550
Mailing Address - Street 2:
Mailing Address - City:LOWELL
Mailing Address - State:AR
Mailing Address - Zip Code:72745-1900
Mailing Address - Country:US
Mailing Address - Phone:479-473-7775
Mailing Address - Fax:
Practice Address - Street 1:3215 N NORTH HILLS BLVD.
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:AR
Practice Address - Zip Code:72703
Practice Address - Country:US
Practice Address - Phone:479-463-7102
Practice Address - Fax:479-463-5987
Is Sole Proprietor?:No
Enumeration Date:2017-04-10
Last Update Date:2021-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARE-13154207P00000X
ALMD.37708207P00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program