Basic Information
| Provider Information | |||||||||
| NPI: | 1871084301 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SIDDONS | ||||||||
| FirstName: | UPTON | ||||||||
| MiddleName: | GARDNER | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | SR. | ||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 11001 EXECUTIVE CENTER DR STE 200 | ||||||||
| Address2: | |||||||||
| City: | LITTLE ROCK | ||||||||
| State: | AR | ||||||||
| PostalCode: | 722114393 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4799965585 | ||||||||
| FaxNumber: | 4799965386 | ||||||||
| Practice Location | |||||||||
| Address1: | 1480 W CENTER ST | ||||||||
| Address2: | |||||||||
| City: | GREENWOOD | ||||||||
| State: | AR | ||||||||
| PostalCode: | 729363449 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4799965585 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/21/2018 | ||||||||
| LastUpdateDate: | 05/10/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 05/10/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | E-12892 | AR | Y | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.