Provider Demographics
NPI:1669468443
Name:CHISHOLM, DAN P (MD)
Entity Type:Individual
Prefix:
First Name:DAN
Middle Name:P
Last Name:CHISHOLM
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 1:11323 ARCADE DR SUITCE C #3080
Mailing Address - Street 2:SUITE 101
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72212
Mailing Address - Country:US
Mailing Address - Phone:501-223-3755
Mailing Address - Fax:
Practice Address - Street 1:4301 W MARKHAM ST STE 101
Practice Address - Street 2:
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72205-7101
Practice Address - Country:US
Practice Address - Phone:501-686-7000
Practice Address - Fax:501-526-6896
Is Sole Proprietor?:No
Enumeration Date:2005-09-27
Last Update Date:2018-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARR25422085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR109785001Medicaid
E17514Medicare UPIN