Provider Demographics
NPI:1053357491
Name:PRUIKSMA, RICHARD T (MD)
Entity type:Individual
Prefix:
First Name:RICHARD
Middle Name:T
Last Name:PRUIKSMA
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:614 E EMMA AVENUE
Mailing Address - Street 2:SUITE 300
Mailing Address - City:SPRINGDALE
Mailing Address - State:AR
Mailing Address - Zip Code:72764-4469
Mailing Address - Country:US
Mailing Address - Phone:479-751-7417
Mailing Address - Fax:479-751-4898
Practice Address - Street 1:500 S MOUNT OLIVE ST
Practice Address - Street 2:SUITE 200
Practice Address - City:SILOAM SPRINGS
Practice Address - State:AR
Practice Address - Zip Code:72761-3602
Practice Address - Country:US
Practice Address - Phone:479-524-9550
Practice Address - Fax:479-524-9552
Is Sole Proprietor?:No
Enumeration Date:2006-06-22
Last Update Date:2014-07-14
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
OK20107207Q00000X
KS04-28209207Q00000X
ARE-0221207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR351793OtherMEDICARE ID
ARE-0221OtherLICENSE
KSBP3752905OtherDEA
110238Medicare PIN
KSF69493Medicare UPIN