Provider Demographics
NPI:1902865579
Name:OAK PARK MEDICAL C,LINIC, P.A.
Entity Type:Organization
Organization Name:OAK PARK MEDICAL C,LINIC, P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:LACKEY
Authorized Official - Middle Name:GENE
Authorized Official - Last Name:MOODY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:870-793-9887
Mailing Address - Street 1:PO BOX 2335
Mailing Address - Street 2:
Mailing Address - City:BATESVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72503-2335
Mailing Address - Country:US
Mailing Address - Phone:870-793-6887
Mailing Address - Fax:870-793-8085
Practice Address - Street 1:1301 WHITE DR
Practice Address - Street 2:
Practice Address - City:BATESVILLE
Practice Address - State:AR
Practice Address - Zip Code:72501-9467
Practice Address - Country:US
Practice Address - Phone:870-793-6887
Practice Address - Fax:870-793-8085
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-21
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARC-4126207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR57250OtherBLUE CROSS
AR57250Medicare ID - Type Unspecified
ARB90436Medicare UPIN