Provider Demographics
NPI:1356323042
Name:FORD, MARY N (MD)
Entity Type:Individual
Prefix:DR
First Name:MARY
Middle Name:N
Last Name:FORD
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 1523
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72702-1523
Mailing Address - Country:US
Mailing Address - Phone:479-571-6038
Mailing Address - Fax:479-582-0222
Practice Address - Street 1:3344 N FUTRALL DR
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:AR
Practice Address - Zip Code:72703-4057
Practice Address - Country:US
Practice Address - Phone:479-521-8200
Practice Address - Fax:479-582-7310
Is Sole Proprietor?:No
Enumeration Date:2005-11-17
Last Update Date:2024-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARE-10346207R00000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3062741OtherBLUE CROSS
TN3388963Medicaid
TN000000003911OtherTENNCARE TLC
TN3388963Medicaid
TNG13945Medicare UPIN
TN080091104Medicare ID - Type UnspecifiedRAILROAD