Provider Demographics
NPI:1356597330
Name:KRAFFT, RYAN THOMAS (DO)
Entity type:Individual
Prefix:
First Name:RYAN
Middle Name:THOMAS
Last Name:KRAFFT
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 1:17 MEDICAL PLZ
Mailing Address - Street 2:
Mailing Address - City:MOUNTAIN HOME
Mailing Address - State:AR
Mailing Address - Zip Code:72653-2918
Mailing Address - Country:US
Mailing Address - Phone:870-508-5900
Mailing Address - Fax:870-508-5995
Practice Address - Street 1:17 MEDICAL PLZ
Practice Address - Street 2:
Practice Address - City:MOUNTAIN HOME
Practice Address - State:AR
Practice Address - Zip Code:72653-2918
Practice Address - Country:US
Practice Address - Phone:870-508-5900
Practice Address - Fax:870-508-5995
Is Sole Proprietor?:No
Enumeration Date:2008-08-11
Last Update Date:2016-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIDO 5101018562208D00000X
SC16562081P2900X
ARE9758208VP0014X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain Medicine
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No2081P2900XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationPain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCSC09596672Medicare PIN
AR518188ZQV2Medicare PIN