Provider Demographics
NPI:1427011410
Name:SHOTTS, CULBER MACK (MD)
Entity Type:Individual
Prefix:
First Name:CULBER
Middle Name:MACK
Last Name:SHOTTS
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 1:4000 LINWOOD DR
Mailing Address - Street 2:SUITE A
Mailing Address - City:PARAGOULD
Mailing Address - State:AR
Mailing Address - Zip Code:72450-7223
Mailing Address - Country:US
Mailing Address - Phone:870-239-8503
Mailing Address - Fax:870-240-2016
Practice Address - Street 1:4000 LINWOOD DR
Practice Address - Street 2:SUITE A
Practice Address - City:PARAGOULD
Practice Address - State:AR
Practice Address - Zip Code:72450-7223
Practice Address - Country:US
Practice Address - Phone:870-239-8503
Practice Address - Fax:870-240-2016
Is Sole Proprietor?:No
Enumeration Date:2006-04-10
Last Update Date:2015-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARC5097207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR102563001Medicaid
AR13494000040OtherQUALCHOICE
AR13494000040OtherQUALCHOICE
080179939Medicare PIN
AR102563001Medicaid
ARD84330Medicare UPIN