Provider Demographics
NPI:1710970637
Name:REVARD, RONALD E (MD)
Entity Type:Individual
Prefix:
First Name:RONALD
Middle Name:E
Last Name:REVARD
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 550
Mailing Address - Street 2:
Mailing Address - City:LOWELL
Mailing Address - State:AR
Mailing Address - Zip Code:72745
Mailing Address - Country:US
Mailing Address - Phone:479-463-7775
Mailing Address - Fax:479-463-7187
Practice Address - Street 1:702 N. SPRING STREET
Practice Address - Street 2:
Practice Address - City:HARRISON
Practice Address - State:AR
Practice Address - Zip Code:72601
Practice Address - Country:US
Practice Address - Phone:870-365-0761
Practice Address - Fax:870-365-0763
Is Sole Proprietor?:No
Enumeration Date:2005-08-25
Last Update Date:2018-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARC-6300207RC0000X
ARC6300207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR110646001Medicaid
AR54329Medicare ID - Type Unspecified
AR110646001Medicaid