Provider Demographics
NPI:1245329663
Name:MATHUR, ASHISH (MD)
Entity type:Individual
Prefix:
First Name:ASHISH
Middle Name:
Last Name:MATHUR
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:643 E 3RD ST
Mailing Address - Street 2:PO BOX 9
Mailing Address - City:GENTRY
Mailing Address - State:AR
Mailing Address - Zip Code:72734-8258
Mailing Address - Country:US
Mailing Address - Phone:479-736-2213
Mailing Address - Fax:479-736-2105
Practice Address - Street 1:643 E 3RD ST
Practice Address - Street 2:
Practice Address - City:GENTRY
Practice Address - State:AR
Practice Address - Zip Code:72734-8258
Practice Address - Country:US
Practice Address - Phone:479-736-2213
Practice Address - Fax:479-736-2105
Is Sole Proprietor?:No
Enumeration Date:2006-10-12
Last Update Date:2011-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK24117207Q00000X
ARE5401207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ARP00620016OtherMEDICARE RAILROAD ARKANSAS
AR165673001Medicaid
AR5N971OtherBCBS OF ARKANSAS
OK200096500BMedicaid
AR5N971Medicare PIN