Provider Demographics
NPI:1740481191
Name:FAIR PARK MEDICAL CLINIC
Entity type:Organization
Organization Name:FAIR PARK MEDICAL CLINIC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:CARL
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:501-663-6262
Mailing Address - Street 1:5320 W. 12TH STREET
Mailing Address - Street 2:
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72206
Mailing Address - Country:US
Mailing Address - Phone:501-663-6262
Mailing Address - Fax:501-663-3189
Practice Address - Street 1:5320 W 12TH ST
Practice Address - Street 2:
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72204-1859
Practice Address - Country:US
Practice Address - Phone:501-663-6262
Practice Address - Fax:501-663-3189
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-31
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARMC2208207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ARC67983Medicare UPIN
AR5B504Medicare ID - Type Unspecified