Provider Demographics
NPI:1194773861
Name:YOUNGBLOOD, THOMAS HUNTER (MD)
Entity type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:HUNTER
Last Name:YOUNGBLOOD
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 1:325 S 6TH PL
Mailing Address - Street 2:
Mailing Address - City:LOWELL
Mailing Address - State:AR
Mailing Address - Zip Code:72745-9704
Mailing Address - Country:US
Mailing Address - Phone:479-636-9234
Mailing Address - Fax:479-717-7557
Practice Address - Street 1:325 S 6TH PL
Practice Address - Street 2:
Practice Address - City:LOWELL
Practice Address - State:AR
Practice Address - Zip Code:72745-9704
Practice Address - Country:US
Practice Address - Phone:479-636-9234
Practice Address - Fax:479-717-7557
Is Sole Proprietor?:No
Enumeration Date:2006-05-05
Last Update Date:2015-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARR38312080A0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080A0000XAllopathic & Osteopathic PhysiciansPediatricsAdolescent Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ARD04412Medicare UPIN
AR50787Medicare ID - Type Unspecified
AR114467001Medicaid