Provider Demographics
NPI:1821085887
Name:STITES, PHILLIP C (MD)
Entity Type:Individual
Prefix:
First Name:PHILLIP
Middle Name:C
Last Name:STITES
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 1:7900 DALLAS STREET
Mailing Address - Street 2:
Mailing Address - City:FORT SMITH
Mailing Address - State:AR
Mailing Address - Zip Code:72903-5690
Mailing Address - Country:US
Mailing Address - Phone:479-242-6647
Mailing Address - Fax:479-250-0505
Practice Address - Street 1:7900 DALLAS STREET
Practice Address - Street 2:
Practice Address - City:FORT SMITH
Practice Address - State:AR
Practice Address - Zip Code:72903-5690
Practice Address - Country:US
Practice Address - Phone:479-242-6647
Practice Address - Fax:479-250-0505
Is Sole Proprietor?:No
Enumeration Date:2005-10-04
Last Update Date:2021-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARE2778207ND0101X, 207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
No207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR142944001Medicaid
ARH35951Medicare UPIN
AR5L844Medicare ID - Type Unspecified