Provider Demographics
NPI:1588641930
Name:CUNNINGHAM, MARK ALAN (MD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:ALAN
Last Name:CUNNINGHAM
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 1:4215 LYNN DR
Mailing Address - Street 2:
Mailing Address - City:EL DORADO
Mailing Address - State:AR
Mailing Address - Zip Code:71730-8670
Mailing Address - Country:US
Mailing Address - Phone:870-862-2442
Mailing Address - Fax:
Practice Address - Street 1:4215 LYNN DR
Practice Address - Street 2:
Practice Address - City:EL DORADO
Practice Address - State:AR
Practice Address - Zip Code:71730-8670
Practice Address - Country:US
Practice Address - Phone:870-862-2442
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-28
Last Update Date:2010-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXD9980207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX150366601Medicaid
TX150366605Medicaid
TX8C2555Medicare ID - Type Unspecified606K
TX8020M6Medicare ID - Type Unspecified607K
TX150366605Medicaid