Provider Demographics
NPI:1609194455
Name:PADDACK, GEOFFREY L (MD)
Entity Type:Individual
Prefix:
First Name:GEOFFREY
Middle Name:L
Last Name:PADDACK
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 3887
Mailing Address - Street 2:
Mailing Address - City:FORT SMITH
Mailing Address - State:AR
Mailing Address - Zip Code:72913-3887
Mailing Address - Country:US
Mailing Address - Phone:479-452-9416
Mailing Address - Fax:479-484-0827
Practice Address - Street 1:5707 JENNY LIND RD
Practice Address - Street 2:
Practice Address - City:FORT SMITH
Practice Address - State:AR
Practice Address - Zip Code:72908-7435
Practice Address - Country:US
Practice Address - Phone:479-452-9416
Practice Address - Fax:479-484-0827
Is Sole Proprietor?:No
Enumeration Date:2010-05-04
Last Update Date:2019-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR390200000X
ARE-80152085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program