Basic Information
Provider Information | |||||||||
NPI: | 1982647616 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | SANDEFUR | ||||||||
FirstName: | BARBARA | ||||||||
MiddleName: | A, | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 500 SOUTH UNIVERSITY | ||||||||
Address2: | SUITE 600 | ||||||||
City: | LITTLE ROCK | ||||||||
State: | AR | ||||||||
PostalCode: | 722055324 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5016643914 | ||||||||
FaxNumber: | 5016645246 | ||||||||
Practice Location | |||||||||
Address1: | 500 SOUTH UNIVERSITY | ||||||||
Address2: | SUITE 101 | ||||||||
City: | LITTLE ROCK | ||||||||
State: | AR | ||||||||
PostalCode: | 722025324 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5016643914 | ||||||||
FaxNumber: | 5016645246 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/13/2006 | ||||||||
LastUpdateDate: | 01/18/2012 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | R3146 | AR | Y |   | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
ID | Type | State | Issuer | Description | 55822 | 01 | AR | BCBS PROVIDER NUMBER | OTHER | 121991001 | 05 | AR |   | MEDICAID |