Provider Demographics
NPI:1306808829
Name:CARRASCO, LUIS M (MD)
Entity type:Individual
Prefix:
First Name:LUIS
Middle Name:M
Last Name:CARRASCO
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 1:614 E EMMA AVE
Mailing Address - Street 2:STE 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 1:1233 WEST POPLAR
Practice Address - Street 2:
Practice Address - City:ROGERS
Practice Address - State:AR
Practice Address - Zip Code:72756-4249
Practice Address - Country:US
Practice Address - Phone:479-636-9235
Practice Address - Fax:479-631-0374
Is Sole Proprietor?:No
Enumeration Date:2006-04-03
Last Update Date:2016-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY33347208000000X
ARE-9613208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64333479Medicaid
AR215360001Medicaid
KY183935OtherGROUP MEDCARE
KY35001775OtherGROUP MEDICAID
KY183935OtherGROUP MEDCARE
AR215360001Medicaid