Provider Demographics
NPI:1518908417
Name:MAHAN, MEREDITH L (MD)
Entity Type:Individual
Prefix:
First Name:MEREDITH
Middle Name:L
Last Name:MAHAN
Suffix:
Gender:F
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 1523
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72702-1523
Mailing Address - Country:US
Mailing Address - Phone:479-571-6038
Mailing Address - Fax:479-582-0222
Practice Address - Street 1:3380 N FUTRALL DR STE 1
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:AR
Practice Address - Zip Code:72703
Practice Address - Country:US
Practice Address - Phone:479-442-7322
Practice Address - Fax:479-442-7379
Is Sole Proprietor?:No
Enumeration Date:2006-06-09
Last Update Date:2021-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARE-0299208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR126198001Medicaid
AR5J563OtherAR BC/BS
AR5J563F430Medicare PIN
AR5J563OtherAR BC/BS
AR5J563Medicare ID - Type Unspecified