Provider Demographics
NPI:1053344986
Name:FOSSEY, CAROL A (MD)
Entity type:Individual
Prefix:DR
First Name:CAROL
Middle Name:A
Last Name:FOSSEY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2384 E GOLDEN OAKS DR
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72703-3152
Mailing Address - Country:US
Mailing Address - Phone:479-443-7687
Mailing Address - Fax:
Practice Address - Street 1:525 N GARLAND AVE
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:AR
Practice Address - Zip Code:72701-3110
Practice Address - Country:US
Practice Address - Phone:479-575-6479
Practice Address - Fax:479-575-8793
Is Sole Proprietor?:No
Enumeration Date:2006-07-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARN-5888207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR15688OtherQUALCHOICE ID NUMBER
AR51751Medicare ID - Type Unspecified
AR15688OtherQUALCHOICE ID NUMBER