Provider Demographics
NPI:1134207483
Name:OZARK DERMATOLOGY CLINIC
Entity type:Organization
Organization Name:OZARK DERMATOLOGY CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:DIANE
Authorized Official - Middle Name:
Authorized Official - Last Name:WILLIAMS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:479-335-1831
Mailing Address - Street 1:4375 N. VANTAGE DRIVE
Mailing Address - Street 2:SUITE 305
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72703-4984
Mailing Address - Country:US
Mailing Address - Phone:479-443-5100
Mailing Address - Fax:479-443-5117
Practice Address - Street 1:4375 N. VANTAGE DRIVE
Practice Address - Street 2:SUITE 305
Practice Address - City:FAYETTEVILLE
Practice Address - State:AR
Practice Address - Zip Code:72703-4984
Practice Address - Country:US
Practice Address - Phone:479-443-5100
Practice Address - Fax:479-443-5117
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-02
Last Update Date:2022-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR7897701OtherAETNA
AR14568002Medicaid
AR14568002Medicaid