Provider Demographics
NPI:1912930967
Name:EDATTUKAREN, VARGHESE (MD)
Entity Type:Individual
Prefix:MR
First Name:VARGHESE
Middle Name:
Last Name:EDATTUKAREN
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 83
Mailing Address - Street 2:1300 CREASON ROAD
Mailing Address - City:CORNING
Mailing Address - State:AR
Mailing Address - Zip Code:72422-0083
Mailing Address - Country:US
Mailing Address - Phone:870-857-3399
Mailing Address - Fax:870-857-9934
Practice Address - Street 1:201 COLONIAL DR
Practice Address - Street 2:
Practice Address - City:WALNUT RIDGE
Practice Address - State:AR
Practice Address - Zip Code:72476-1410
Practice Address - Country:US
Practice Address - Phone:870-886-5507
Practice Address - Fax:870-886-5632
Is Sole Proprietor?:No
Enumeration Date:2006-07-09
Last Update Date:2014-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARR4370207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR122364001Medicaid
AR122364001Medicaid
AR57297Medicare PIN
AR55994Medicare PIN
A08112Medicare UPIN