Basic Information
| Provider Information | |||||||||
| NPI: | 1972575702 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KINSLOW | ||||||||
| FirstName: | IVORY | ||||||||
| MiddleName: | AMELIA | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 310 THOMPSON AVE | ||||||||
| Address2: | |||||||||
| City: | EL DORADO | ||||||||
| State: | AR | ||||||||
| PostalCode: | 717304569 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8708624216 | ||||||||
| FaxNumber: | 8708629011 | ||||||||
| Practice Location | |||||||||
| Address1: | 310 THOMPSON AVE | ||||||||
| Address2: | |||||||||
| City: | EL DORADO | ||||||||
| State: | AR | ||||||||
| PostalCode: | 717304569 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8708624216 | ||||||||
| FaxNumber: | 8708629011 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/06/2006 | ||||||||
| LastUpdateDate: | 10/16/2012 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207W00000X | C7743 | AR | Y | Allopathic & Osteopathic Physicians | Ophthalmology |
ID Information
| ID | Type | State | Issuer | Description | 180037761 | 01 | AR | RAILROAD MEDICARE | OTHER | 15205000000 | 01 | AR | QUALCHOICE | OTHER | 126721001 | 05 | AR | MEDICAID |