Provider Demographics
NPI:1518181767
Name:FANKHAUSER, JOEL B (MD)
Entity Type:Individual
Prefix:
First Name:JOEL
Middle Name:B
Last Name:FANKHAUSER
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 1:2103 S 54TH ST
Mailing Address - Street 2:SUITE 1
Mailing Address - City:ROGERS
Mailing Address - State:AR
Mailing Address - Zip Code:72758-8169
Mailing Address - Country:US
Mailing Address - Phone:479-268-4504
Mailing Address - Fax:
Practice Address - Street 1:2103 S 54TH ST
Practice Address - Street 2:SUITE 1
Practice Address - City:ROGERS
Practice Address - State:AR
Practice Address - Zip Code:72758-8169
Practice Address - Country:US
Practice Address - Phone:479-268-4504
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-12
Last Update Date:2015-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARE-6417207RA0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RA0000XAllopathic & Osteopathic PhysiciansInternal MedicineAdolescent Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR5AF16Medicare PIN
AR184172001Medicaid