Provider Demographics
NPI:1295722668
Name:MAXWELL, RALPH MARTIN (DO)
Entity type:Individual
Prefix:
First Name:RALPH
Middle Name:MARTIN
Last Name:MAXWELL
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:811 HIGHWAY 65 S
Mailing Address - Street 2:PO BOX 830
Mailing Address - City:DUMAS
Mailing Address - State:AR
Mailing Address - Zip Code:71639-3006
Mailing Address - Country:US
Mailing Address - Phone:870-382-8261
Mailing Address - Fax:870-382-8140
Practice Address - Street 1:811 HIGHWAY 65 S
Practice Address - Street 2:
Practice Address - City:DUMAS
Practice Address - State:AR
Practice Address - Zip Code:71639-3006
Practice Address - Country:US
Practice Address - Phone:870-382-8261
Practice Address - Fax:870-382-8140
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-30
Last Update Date:2011-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID00356207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA0194584OtherDEPT OF LABOR & INDUSTRY
IDS5494OtherBLUE CROSS OF ID
ID807073500Medicaid
ID000010149459OtherREGENCE BS OF ID
WA8434870Medicaid
P00192008OtherRAILROAD MEDICARE
WA8434870Medicaid
ID000010149459OtherREGENCE BS OF ID