Provider Demographics
NPI:1255398400
Name:FADDIS, LANCE A (MD)
Entity type:Individual
Prefix:DR
First Name:LANCE
Middle Name:A
Last Name:FADDIS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:805 W CENTERTON BLVD
Mailing Address - Street 2:
Mailing Address - City:CENTERTON
Mailing Address - State:AR
Mailing Address - Zip Code:72719-9705
Mailing Address - Country:US
Mailing Address - Phone:479-795-1301
Mailing Address - Fax:479-795-1304
Practice Address - Street 1:805 W CENTERTON BLVD
Practice Address - Street 2:
Practice Address - City:CENTERTON
Practice Address - State:AR
Practice Address - Zip Code:72719-9705
Practice Address - Country:US
Practice Address - Phone:479-795-1301
Practice Address - Fax:479-795-1304
Is Sole Proprietor?:No
Enumeration Date:2006-04-28
Last Update Date:2011-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARE3957207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR154233001Medicaid
AR5M930Medicare ID - Type Unspecified
ARI06704Medicare UPIN