Provider Demographics
NPI:1821066374
Name:DODD, MICHAEL O (MS)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:O
Last Name:DODD
Suffix:
Gender:M
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:715 N COLLEGE AVE
Mailing Address - Street 2:
Mailing Address - City:EL DORADO
Mailing Address - State:AR
Mailing Address - Zip Code:71730-4403
Mailing Address - Country:US
Mailing Address - Phone:870-862-7921
Mailing Address - Fax:
Practice Address - Street 1:715 N COLLEGE AVE
Practice Address - Street 2:
Practice Address - City:EL DORADO
Practice Address - State:AR
Practice Address - Zip Code:71730-4403
Practice Address - Country:US
Practice Address - Phone:870-862-7921
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-10
Last Update Date:2008-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR91-17E103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR5T974OtherBLUE CROSS