Provider Demographics
NPI:1972728988
Name:ENNS, MICHAEL WAYNE (MD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:WAYNE
Last Name:ENNS
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 1:1100 N UNIVERSITY AVE STE 142
Mailing Address - Street 2:
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72207-6344
Mailing Address - Country:US
Mailing Address - Phone:501-404-9582
Mailing Address - Fax:
Practice Address - Street 1:1100 N UNIVERSITY AVE STE 142
Practice Address - Street 2:
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72207-6344
Practice Address - Country:US
Practice Address - Phone:501-404-9582
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-16
Last Update Date:2024-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARE46572085R0204X, 202K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes202K00000XAllopathic & Osteopathic PhysiciansPhlebology
Yes2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR5I047OtherAR BC/BS
AR189400001Medicaid
AR189400001Medicaid
AR5AM35Medicare PIN