Provider Demographics
NPI:1164536553
Name:KAUFMAN, MITCHELL HESTON (MD)
Entity Type:Individual
Prefix:DR
First Name:MITCHELL
Middle Name:HESTON
Last Name:KAUFMAN
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 1:10001 LILE DR
Mailing Address - Street 2:
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72205-6217
Mailing Address - Country:US
Mailing Address - Phone:201-227-8000
Mailing Address - Fax:501-221-5850
Practice Address - Street 1:10001 LILE DR
Practice Address - Street 2:
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72205-6217
Practice Address - Country:US
Practice Address - Phone:201-227-8000
Practice Address - Fax:501-221-5850
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-19
Last Update Date:2016-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG579022084N0400X
SC401202084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR163580001Medicaid
SC401201Medicaid
ARE-5065OtherSTATE LICENSE
AR5N745OtherBLUE CROSS BLUE SHIELD
SCSC89077951Medicare PIN
AR163580001Medicaid