Provider Demographics
NPI:1891788428
Name:LOVE, MIKEAL ROBERT (MD)
Entity Type:Individual
Prefix:
First Name:MIKEAL
Middle Name:ROBERT
Last Name:LOVE
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 1:174 E CYDNEE ST
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72703-3987
Mailing Address - Country:US
Mailing Address - Phone:512-773-9682
Mailing Address - Fax:
Practice Address - Street 1:1100 N COLLEGE AVE
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:AR
Practice Address - Zip Code:72703-1944
Practice Address - Country:US
Practice Address - Phone:479-443-4301
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-08-30
Last Update Date:2023-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXH7322207V00000X
ARE-13080207VH0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VH0002XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyHospice and Palliative Medicine
No207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXTXB118821OtherMEDICARE PTAN
TXTXB118821OtherMEDICARE PTAN
TX131762007Medicaid
TX131762005Medicaid