Provider Demographics
NPI:1265261572
Name:TRAVIS, DYLAN (MD)
Entity type:Individual
Prefix:
First Name:DYLAN
Middle Name:
Last Name:TRAVIS
Suffix:
Gender:
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:616 COUNTY ROAD 765
Mailing Address - Street 2:
Mailing Address - City:BROOKLAND
Mailing Address - State:AR
Mailing Address - Zip Code:72417-8766
Mailing Address - Country:US
Mailing Address - Phone:870-351-2842
Mailing Address - Fax:
Practice Address - Street 1:616 COUNTY ROAD 765
Practice Address - Street 2:
Practice Address - City:BROOKLAND
Practice Address - State:AR
Practice Address - Zip Code:72417-8766
Practice Address - Country:US
Practice Address - Phone:870-351-2842
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-07-26
Last Update Date:2025-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
AR1265261572207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program