Provider Demographics
NPI:1508848417
Name:KOONCE, THOMAS WAYNE (MD)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:WAYNE
Last Name:KOONCE
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:PO BOX 55050
Mailing Address - Street 2:
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72215-5050
Mailing Address - Country:US
Mailing Address - Phone:501-219-8777
Mailing Address - Fax:501-907-6522
Practice Address - Street 1:8901 CARTI WAY
Practice Address - Street 2:
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72205-6523
Practice Address - Country:US
Practice Address - Phone:501-219-8777
Practice Address - Fax:501-907-6522
Is Sole Proprietor?:No
Enumeration Date:2005-11-16
Last Update Date:2015-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARC-59252085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR112961001Medicaid
AR52974Medicare PIN
ARB90360Medicare UPIN