Basic Information
| Provider Information | |||||||||
| NPI: | 1730118290 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SUDBRINK | ||||||||
| FirstName: | DAVID | ||||||||
| MiddleName: | W | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5401 ELLSWORTH ROAD | ||||||||
| Address2: | |||||||||
| City: | FORT SMITH | ||||||||
| State: | AR | ||||||||
| PostalCode: | 729033219 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4793141101 | ||||||||
| FaxNumber: | 4793144704 | ||||||||
| Practice Location | |||||||||
| Address1: | 3501 W.E. KNIGHT DRIVE | ||||||||
| Address2: | |||||||||
| City: | FORT SMITH | ||||||||
| State: | AR | ||||||||
| PostalCode: | 729036248 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4797096700 | ||||||||
| FaxNumber: | 4797096768 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/30/2006 | ||||||||
| LastUpdateDate: | 12/07/2012 | ||||||||
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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 | 207X00000X | E-3251 | AR | Y | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |
ID Information
| ID | Type | State | Issuer | Description | 145891001 | 05 | AR | MEDICAID |