Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 207PP0204X | Pediatric Emergency Physician | E-6020 | AR |
Y | 208000000X | Pediatrician | E-6020 | AR |
NPI | 1710106042 |
---|---|
Provider Name | Gideon S Mecum |
First Address | Fayetteville, AR 72703-4938 |
Second Address | Fayetteville, AR 72703-4424 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 25/04/2007 |
Last Update Date | 18/02/2019 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
177619001 | (05) | AR |