Provider Demographics
NPI:1144275413
Name:PICKHARDT, MARK G (MD)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:G
Last Name:PICKHARDT
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1523
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72702-1523
Mailing Address - Country:US
Mailing Address - Phone:479-571-6038
Mailing Address - Fax:479-582-0222
Practice Address - Street 1:3302 N NORTHHILLS BLVD
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:AR
Practice Address - Zip Code:72703-4008
Practice Address - Country:US
Practice Address - Phone:479-582-3366
Practice Address - Fax:479-571-6572
Is Sole Proprietor?:No
Enumeration Date:2006-05-24
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARC7319207V00000X
ARC-7319207VG0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecology
No207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR119159001Medicaid
AR54558OtherBLUE
AR119159001Medicaid
B30180Medicare UPIN
AR54558Medicare ID - Type Unspecified