Basic Information
| Provider Information | |||||||||
| NPI: | 1851443832 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FLETCHER | ||||||||
| FirstName: | TERRY | ||||||||
| MiddleName: | GRANT | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD PHD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 108 N SHACKLEFORD RD | ||||||||
| Address2: | |||||||||
| City: | LITTLE ROCK | ||||||||
| State: | AR | ||||||||
| PostalCode: | 722112840 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5017122571 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 108 N SHACKLEFORD RD | ||||||||
| Address2: | |||||||||
| City: | LITTLE ROCK | ||||||||
| State: | AR | ||||||||
| PostalCode: | 722112840 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5017122571 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/18/2007 | ||||||||
| LastUpdateDate: | 04/05/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/05/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | E-5050 | AR | N | Allopathic & Osteopathic Physicians | Anesthesiology | 207LP2900X | E-5050 | AR | Y | Allopathic & Osteopathic Physicians | Anesthesiology | Pain Medicine |
ID Information
| ID | Type | State | Issuer | Description | 5N783 | 01 | AR | AR BLUE CROSS/BLUE SHIELD | OTHER | 163885001 | 05 | AR | MEDICAID | P00412911 | 01 | AR | RAILROAD MEDICARE | OTHER |