Provider Demographics
NPI:1982685723
Name:GEORGE, TODD WILSON (MPT)
Entity Type:Individual
Prefix:
First Name:TODD
Middle Name:WILSON
Last Name:GEORGE
Suffix:
Gender:M
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3030 PINE ST
Mailing Address - Street 2:
Mailing Address - City:ARKADELPHIA
Mailing Address - State:AR
Mailing Address - Zip Code:71923-5325
Mailing Address - Country:US
Mailing Address - Phone:870-246-8623
Mailing Address - Fax:870-246-8694
Practice Address - Street 1:3030 PINE ST
Practice Address - Street 2:
Practice Address - City:ARKADELPHIA
Practice Address - State:AR
Practice Address - Zip Code:71923-5325
Practice Address - Country:US
Practice Address - Phone:870-246-8623
Practice Address - Fax:870-246-8694
Is Sole Proprietor?:No
Enumeration Date:2005-11-09
Last Update Date:2009-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARPT 909225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR141081721Medicaid
AR56477OtherARKANSAS BCBS