Provider Demographics
NPI:1750386876
Name:EMBRY, TRAVIS DALE (MD)
Entity type:Individual
Prefix:
First Name:TRAVIS
Middle Name:DALE
Last Name:EMBRY
Suffix:
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 1060
Mailing Address - Street 2:
Mailing Address - City:MARSHALL
Mailing Address - State:AR
Mailing Address - Zip Code:72650-1060
Mailing Address - Country:US
Mailing Address - Phone:870-448-5101
Mailing Address - Fax:870-448-3767
Practice Address - Street 1:934 NORTH GASKILL
Practice Address - Street 2:
Practice Address - City:HUNTSVILLE
Practice Address - State:AR
Practice Address - Zip Code:72740-1319
Practice Address - Country:US
Practice Address - Phone:479-738-5500
Practice Address - Fax:479-738-1350
Is Sole Proprietor?:No
Enumeration Date:2005-06-15
Last Update Date:2018-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARN8375207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR5K542OtherARKANSAS BLUE CROSS
AR5K542B477OtherMEDICARE PIN
ARP00014909OtherRAILROAD MEDICARE
AR131873001Medicaid
AR5K542OtherARKANSAS BLUE CROSS