Basic Information
Provider Information | |||||||||
NPI: | 1275581027 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | WETSELL | ||||||||
FirstName: | BARRY | ||||||||
MiddleName: | KEITH | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | D.O. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 9178 | ||||||||
Address2: |   | ||||||||
City: | RUSSELLVILLE | ||||||||
State: | AR | ||||||||
PostalCode: | 72811 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4799687930 | ||||||||
FaxNumber: | 4799684331 | ||||||||
Practice Location | |||||||||
Address1: | 3215 N NORTHHILLS BLVD | ||||||||
Address2: |   | ||||||||
City: | FAYETTEVILLE | ||||||||
State: | AR | ||||||||
PostalCode: | 727034424 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4799687930 | ||||||||
FaxNumber: | 4799684331 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/04/2006 | ||||||||
LastUpdateDate: | 06/10/2010 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | E-4573 | AR | Y |   | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
ID | Type | State | Issuer | Description | 158399003 | 05 | AR |   | MEDICAID | 200063050A | 05 | OK |   | MEDICAID |