Provider Demographics
NPI:1720054125
Name:BOLLEN, ALTIMUS RAY (MD)
Entity Type:Individual
Prefix:DR
First Name:ALTIMUS
Middle Name:RAY
Last Name:BOLLEN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:RAY
Other - Middle Name:
Other - Last Name:BOLLEN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:11001 EXECUTIVE CENTER DR
Mailing Address - Street 2:SUITE 200
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72211-4316
Mailing Address - Country:US
Mailing Address - Phone:501-812-7587
Mailing Address - Fax:501-812-7777
Practice Address - Street 1:1002 SCHNEIDER DR
Practice Address - Street 2:SUITE 104
Practice Address - City:MALVERN
Practice Address - State:AR
Practice Address - Zip Code:72104-4816
Practice Address - Country:US
Practice Address - Phone:501-337-9066
Practice Address - Fax:501-332-5265
Is Sole Proprietor?:No
Enumeration Date:2006-02-24
Last Update Date:2008-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARC6072207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ARP00046OtherNOVASYS
AR5401027OtherAETNA
AR102657001Medicaid
AR12692000000OtherQUALCHOICE
AR9292900OtherCIGNA
AR277387OtherHEALTHLINK
ARMG38450OtherUNITED HEALTHCARE
AR0904380007Medicare NSC
AR110143320Medicare PIN
AR277387OtherHEALTHLINK
AR9292900OtherCIGNA