Provider Demographics
NPI:1316478845
Name:ROARK, CARLY (MD)
Entity type:Individual
Prefix:
First Name:CARLY
Middle Name:
Last Name:ROARK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:625 UNITED DR STE 360
Mailing Address - Street 2:
Mailing Address - City:CONWAY
Mailing Address - State:AR
Mailing Address - Zip Code:72032-7831
Mailing Address - Country:US
Mailing Address - Phone:501-358-6892
Mailing Address - Fax:
Practice Address - Street 1:625 UNITED DR STE 360
Practice Address - Street 2:
Practice Address - City:CONWAY
Practice Address - State:AR
Practice Address - Zip Code:72032-7831
Practice Address - Country:US
Practice Address - Phone:501-358-6892
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-26
Last Update Date:2020-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARE-13303208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics