Provider Demographics
NPI:1669603064
Name:DEIMEL, GEORGE W IV (MD)
Entity type:Individual
Prefix:
First Name:GEORGE
Middle Name:W
Last Name:DEIMEL
Suffix:IV
Gender:M
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:PO BOX 1608
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72702-1608
Mailing Address - Country:US
Mailing Address - Phone:479-521-2752
Mailing Address - Fax:479-521-4603
Practice Address - Street 1:3317 N WIMBERLY DR
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:AR
Practice Address - Zip Code:72703-4056
Practice Address - Country:US
Practice Address - Phone:479-521-2752
Practice Address - Fax:479-521-4603
Is Sole Proprietor?:No
Enumeration Date:2009-08-03
Last Update Date:2021-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARE-8659208100000X, 2081P2900X, 208100000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Yes2081P2900XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationPain Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR206486001Medicaid
AR5JJ87OtherBLUE CROSS BLUE SHEILD
AR206486001Medicaid
AR206486001Medicaid