Provider Demographics
NPI:1609211234
Name:MENGARELLI, EDDIE ANTHONY (MD)
Entity Type:Individual
Prefix:DR
First Name:EDDIE
Middle Name:ANTHONY
Last Name:MENGARELLI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:3689 N STEELE BLVD
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72703-5347
Mailing Address - Country:US
Mailing Address - Phone:479-521-2555
Mailing Address - Fax:479-521-6761
Practice Address - Street 1:3689 N STEELE BLVD
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:AR
Practice Address - Zip Code:72703
Practice Address - Country:US
Practice Address - Phone:479-521-2555
Practice Address - Fax:479-521-6761
Is Sole Proprietor?:No
Enumeration Date:2013-05-09
Last Update Date:2019-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARE-10354207W00000X, 207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
ARE-10354OtherARKANSAS MEDICAL LICENSE
TX574720OtherTEXAS PHYSICIAN IN TRAINING ID NUMBER