Provider Demographics
NPI:1700106549
Name:SHIROLYN MOFFETT M.D.,P.A.
Entity Type:Organization
Organization Name:SHIROLYN MOFFETT M.D.,P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:SHIROLYN
Authorized Official - Middle Name:RUTH
Authorized Official - Last Name:MOFFETT
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:870-204-5129
Mailing Address - Street 1:715 W SHERMAN AVE
Mailing Address - Street 2:SUITE D
Mailing Address - City:HARRISON
Mailing Address - State:AR
Mailing Address - Zip Code:72601-2743
Mailing Address - Country:US
Mailing Address - Phone:870-204-5129
Mailing Address - Fax:870-204-5131
Practice Address - Street 1:715 W SHERMAN AVE
Practice Address - Street 2:SUITE D
Practice Address - City:HARRISON
Practice Address - State:AR
Practice Address - Zip Code:72601-2743
Practice Address - Country:US
Practice Address - Phone:870-204-5129
Practice Address - Fax:870-204-5131
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-06-03
Last Update Date:2010-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARE0693207QA0505X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR131508001Medicaid
ARG45118Medicare UPIN
AR5K406Medicare PIN