Basic Information
| Provider Information | |||||||||
| NPI: | 1962466748 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PATRICK | ||||||||
| FirstName: | DONALD | ||||||||
| MiddleName: | L | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 497 | ||||||||
| Address2: | |||||||||
| City: | AUGUSTA | ||||||||
| State: | AR | ||||||||
| PostalCode: | 720060497 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8703473524 | ||||||||
| FaxNumber: | 8703472023 | ||||||||
| Practice Location | |||||||||
| Address1: | 305 RODGERS DR | ||||||||
| Address2: | |||||||||
| City: | SEARCY | ||||||||
| State: | AR | ||||||||
| PostalCode: | 721437432 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5012030857 | ||||||||
| FaxNumber: | 5012030864 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/17/2006 | ||||||||
| LastUpdateDate: | 03/17/2018 | ||||||||
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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 | 2086S0129X | R2139 | AR | N | Allopathic & Osteopathic Physicians | Surgery | Vascular Surgery | 208G00000X | K8415 | TX | N | Allopathic & Osteopathic Physicians | Thoracic Surgery (Cardiothoracic Vascular Surgery) | 208D00000X | R-2139 | AR | Y | Allopathic & Osteopathic Physicians | General Practice |
ID Information
| ID | Type | State | Issuer | Description | 105640001 | 05 | AR | MEDICAID |