Provider Demographics
NPI:1770504458
Name:ORGAIN, ROBERT RUSSELL (OD)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:RUSSELL
Last Name:ORGAIN
Suffix:
Gender:M
Credentials:OD
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 9628
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72703-0028
Mailing Address - Country:US
Mailing Address - Phone:479-521-2020
Mailing Address - Fax:888-533-6054
Practice Address - Street 1:3316 W GROVE DR STE 1
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:AR
Practice Address - Zip Code:72704-5003
Practice Address - Country:US
Practice Address - Phone:479-521-2020
Practice Address - Fax:888-533-6054
Is Sole Proprietor?:No
Enumeration Date:2006-07-21
Last Update Date:2019-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR2412152W00000X, 152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR126253722Medicaid
TX040716501Medicaid
TXU47366Medicare UPIN
AR126253722Medicaid