Basic Information
| Provider Information | |||||||||
| NPI: | 1184843419 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MARTIN | ||||||||
| FirstName: | ANDREW | ||||||||
| MiddleName: | ARTHUR | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 845347 | ||||||||
| Address2: | |||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 752845347 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2146483903 | ||||||||
| FaxNumber: | 2146482481 | ||||||||
| Practice Location | |||||||||
| Address1: | 2601 GENE GEORGE BLVD | ||||||||
| Address2: | |||||||||
| City: | SPRINGDALE | ||||||||
| State: | AR | ||||||||
| PostalCode: | 727620845 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7947256801 | ||||||||
| FaxNumber: | 4797256577 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/25/2007 | ||||||||
| LastUpdateDate: | 01/21/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/21/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | E-6115 | AR | Y | Allopathic & Osteopathic Physicians | Pediatrics | 2080P0207X | P7666 | TX | N | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Hematology-Oncology |
ID Information
| ID | Type | State | Issuer | Description | 177405001 | 05 | AR | MEDICAID |