Provider Demographics
NPI:1962648980
Name:VANDERPOOL, ROY DOUGLAS (MD)
Entity Type:Individual
Prefix:
First Name:ROY
Middle Name:DOUGLAS
Last Name:VANDERPOOL
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 1:2552 E. JOYCE BLVD.
Mailing Address - Street 2:SUITE B
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72703-4553
Mailing Address - Country:US
Mailing Address - Phone:479-571-8585
Mailing Address - Fax:479-571-4005
Practice Address - Street 1:2552 E. JOYCE BLVD.
Practice Address - Street 2:SUITE B
Practice Address - City:FAYETTEVILLE
Practice Address - State:AR
Practice Address - Zip Code:72703-4553
Practice Address - Country:US
Practice Address - Phone:479-571-8585
Practice Address - Fax:479-571-4005
Is Sole Proprietor?:Yes
Enumeration Date:2008-12-22
Last Update Date:2022-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARC7986208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
ARF37315Medicare UPIN