Provider Demographics
NPI:1659596633
Name:LORETTA DEPALO, M.D, P.A.
Entity Type:Organization
Organization Name:LORETTA DEPALO, M.D, P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:LORETTA
Authorized Official - Middle Name:
Authorized Official - Last Name:DEPALO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:501-219-7904
Mailing Address - Street 1:1701 S SHACKLEFORD RD
Mailing Address - Street 2:
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72211-4335
Mailing Address - Country:US
Mailing Address - Phone:501-219-7904
Mailing Address - Fax:501-219-7909
Practice Address - Street 1:1701 S SHACKLEFORD RD
Practice Address - Street 2:
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72211-4335
Practice Address - Country:US
Practice Address - Phone:501-219-7904
Practice Address - Fax:501-219-7909
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-16
Last Update Date:2012-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR207PE0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207PE0005XAllopathic & Osteopathic PhysiciansEmergency MedicineUndersea and Hyperbaric MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR125797001Medicaid
ARE0806OtherELECTRONIC SUBMITTER
ARE0806OtherELECTRONIC SUBMITTER