Basic Information
| Provider Information | |||||||||
| NPI: | 1538137500 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | OLDENBERG | ||||||||
| FirstName: | DENISE | ||||||||
| MiddleName: | T | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 249 | ||||||||
| Address2: | |||||||||
| City: | SALEM | ||||||||
| State: | AR | ||||||||
| PostalCode: | 725760249 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8702574110 | ||||||||
| FaxNumber: | 8702574112 | ||||||||
| Practice Location | |||||||||
| Address1: | 1 WEST CHEROKEE VILLAGE MALL | ||||||||
| Address2: | |||||||||
| City: | CHEROKEE VILLAGE | ||||||||
| State: | AR | ||||||||
| PostalCode: | 72529 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8702574110 | ||||||||
| FaxNumber: | 8702574112 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/08/2006 | ||||||||
| LastUpdateDate: | 05/12/2010 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | R3890 | AR | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 114697001 | 05 | AR | MEDICAID | 203828306 | 05 | MO | MEDICAID |