Provider Demographics
NPI:1104887215
Name:MAGLOTHIN, DOUGLAS (MD)
Entity type:Individual
Prefix:
First Name:DOUGLAS
Middle Name:
Last Name:MAGLOTHIN
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 1:1111 WINDOVER RD
Mailing Address - Street 2:
Mailing Address - City:JONESBORO
Mailing Address - State:AR
Mailing Address - Zip Code:72401-6159
Mailing Address - Country:US
Mailing Address - Phone:870-935-5432
Mailing Address - Fax:870-935-4887
Practice Address - Street 1:1111 WINDOVER RD
Practice Address - Street 2:
Practice Address - City:JONESBORO
Practice Address - State:AR
Practice Address - Zip Code:72401-6159
Practice Address - Country:US
Practice Address - Phone:870-935-5432
Practice Address - Fax:870-935-4887
Is Sole Proprietor?:No
Enumeration Date:2006-03-29
Last Update Date:2007-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARC-5726207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR53257Medicare ID - Type Unspecified
ARB90407Medicare UPIN