Provider Demographics
NPI:1508837485
Name:KLUCK, CARL WESLEY (MD)
Entity Type:Individual
Prefix:DR
First Name:CARL
Middle Name:WESLEY
Last Name:KLUCK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:2850 TWIN RIVERS DR
Mailing Address - Street 2:
Mailing Address - City:ARKADELPHIA
Mailing Address - State:AR
Mailing Address - Zip Code:71923
Mailing Address - Country:US
Mailing Address - Phone:870-246-8036
Mailing Address - Fax:870-246-7164
Practice Address - Street 1:2850 TWIN RIVERS DR
Practice Address - Street 2:
Practice Address - City:ARKADELPHIA
Practice Address - State:AR
Practice Address - Zip Code:71923-4212
Practice Address - Country:US
Practice Address - Phone:870-246-8036
Practice Address - Fax:870-246-7164
Is Sole Proprietor?:No
Enumeration Date:2006-01-30
Last Update Date:2013-09-25
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
ARC-5937208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR105305001Medicaid
ARB90353Medicare UPIN