Basic Information
| Provider Information | |||||||||
| NPI: | 1518912138 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GOLD | ||||||||
| FirstName: | ADAM | ||||||||
| MiddleName: | CRAIG | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 3887 | ||||||||
| Address2: | |||||||||
| City: | FORT SMITH | ||||||||
| State: | AR | ||||||||
| PostalCode: | 729133887 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4794529416 | ||||||||
| FaxNumber: | 4794840827 | ||||||||
| Practice Location | |||||||||
| Address1: | 5707 JENNY LIND RD | ||||||||
| Address2: | |||||||||
| City: | FORT SMITH | ||||||||
| State: | AR | ||||||||
| PostalCode: | 729087435 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4794529416 | ||||||||
| FaxNumber: | 4794840829 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/23/2006 | ||||||||
| LastUpdateDate: | 05/08/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | E1396 | AR | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 100038450A | 01 | OK | OK MEDICAID | OTHER | 132785001 | 05 | AR | MEDICAID |