Provider Demographics
NPI:1366490997
Name:NORTHWEST DERMATOLOGY CLINIC, P.A.
Entity Type:Organization
Organization Name:NORTHWEST DERMATOLOGY CLINIC, P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:R
Authorized Official - Last Name:WHARTON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:479-750-7200
Mailing Address - Street 1:5100 S THOMPSON ST # 212
Mailing Address - Street 2:
Mailing Address - City:SPRINGDALE
Mailing Address - State:AR
Mailing Address - Zip Code:72764-6933
Mailing Address - Country:US
Mailing Address - Phone:479-750-7200
Mailing Address - Fax:479-750-7202
Practice Address - Street 1:5100 S THOMPSON ST # 212
Practice Address - Street 2:
Practice Address - City:SPRINGDALE
Practice Address - State:AR
Practice Address - Zip Code:72764-6933
Practice Address - Country:US
Practice Address - Phone:479-750-7200
Practice Address - Fax:479-750-7202
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-05
Last Update Date:2010-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARMC1781207N00000X, 207ND0101X, 207ND0900X, 207NS0135X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207ND0900XAllopathic & Osteopathic PhysiciansDermatologyDermatopathologyGroup - Multi-Specialty
No207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Multi-Specialty
No207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic SurgeryGroup - Multi-Specialty
No207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural DermatologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR133978002Medicaid
AR133978002Medicaid