Provider Demographics
NPI:1497876460
Name:SEGLEM, DOUGLAS E (DO)
Entity Type:Individual
Prefix:
First Name:DOUGLAS
Middle Name:E
Last Name:SEGLEM
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:P.O. BOX 11350
Mailing Address - Street 2:
Mailing Address - City:FORT SMITH
Mailing Address - State:AR
Mailing Address - Zip Code:72917
Mailing Address - Country:US
Mailing Address - Phone:479-314-4635
Mailing Address - Fax:479-314-4634
Practice Address - Street 1:7301 ROGERS AVE
Practice Address - Street 2:
Practice Address - City:FORT SMITH
Practice Address - State:AR
Practice Address - Zip Code:72903
Practice Address - Country:US
Practice Address - Phone:479-314-4635
Practice Address - Fax:479-314-4634
Is Sole Proprietor?:No
Enumeration Date:2007-04-03
Last Update Date:2010-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARE-52812080N0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080N0001XAllopathic & Osteopathic PhysiciansPediatricsNeonatal-Perinatal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR174236003Medicaid
AR5H206Medicare PIN