Provider Demographics
NPI:1487655247
Name:MOFFETT, T ROBERT JR (MD)
Entity Type:Individual
Prefix:DR
First Name:T
Middle Name:ROBERT
Last Name:MOFFETT
Suffix:JR
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 1:11300 N RODNEY PARHAM RD
Mailing Address - Street 2:SUITE 210
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72212-4153
Mailing Address - Country:US
Mailing Address - Phone:501-663-4100
Mailing Address - Fax:501-663-4145
Practice Address - Street 1:11300 N RODNEY PARHAM RD
Practice Address - Street 2:SUITE 210
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72212-4153
Practice Address - Country:US
Practice Address - Phone:501-663-4100
Practice Address - Fax:501-663-4145
Is Sole Proprietor?:No
Enumeration Date:2005-08-02
Last Update Date:2010-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARR4045174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR11923000000OtherQUALCHOICE
AR117396001Medicaid
ARC67362Medicare UPIN
AR117396001Medicaid
240003195Medicare PIN