Provider Demographics
NPI:1215907894
Name:VONLANTHEN, MARYELLE GEORGETTE (MD)
Entity type:Individual
Prefix:
First Name:MARYELLE
Middle Name:GEORGETTE
Last Name:VONLANTHEN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:MARYELLE
Other - Middle Name:GEORGETTE
Other - Last Name:COMPTON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:1515 S BOWMAN RD
Mailing Address - Street 2:SUITE B
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72211-4207
Mailing Address - Country:US
Mailing Address - Phone:501-228-7171
Mailing Address - Fax:501-228-5462
Practice Address - Street 1:1515 S BOWMAN RD
Practice Address - Street 2:SUITE B
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72211-4207
Practice Address - Country:US
Practice Address - Phone:501-228-7171
Practice Address - Fax:501-228-5462
Is Sole Proprietor?:No
Enumeration Date:2006-01-25
Last Update Date:2007-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARC8512208000000X, 2080P0206X
TXG9896208000000X, 2080P0206X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0206XAllopathic & Osteopathic PhysiciansPediatricsPediatric Gastroenterology
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
ARC8512OtherSTATE LICENSE
TXG9896OtherSTATE LICENSE
ARC8512OtherSTATE LICENSE
ARE80360Medicare UPIN