Provider Demographics
NPI:1891856837
Name:OZARK MOUNTAIN ORTHOPEDIC CLINIC, PA
Entity Type:Organization
Organization Name:OZARK MOUNTAIN ORTHOPEDIC CLINIC, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:ARTHUR
Authorized Official - Last Name:WALLER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:501-362-6631
Mailing Address - Street 1:1708 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:HEBER SPRINGS
Mailing Address - State:AR
Mailing Address - Zip Code:72543-2823
Mailing Address - Country:US
Mailing Address - Phone:501-362-6631
Mailing Address - Fax:
Practice Address - Street 1:1708 W MAIN ST
Practice Address - Street 2:
Practice Address - City:HEBER SPRINGS
Practice Address - State:AR
Practice Address - Zip Code:72543-2823
Practice Address - Country:US
Practice Address - Phone:501-362-6631
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-13
Last Update Date:2009-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARR-4651207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR140217001Medicaid
AR=========OtherTAX I.D.
AR5L439Medicare ID - Type Unspecified