Provider Demographics
NPI:1366430126
Name:INGRAM, RALPH N (MD)
Entity type:Individual
Prefix:
First Name:RALPH
Middle Name:N
Last Name:INGRAM
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:PO BOX 1824
Mailing Address - Street 2:
Mailing Address - City:FORT SMITH
Mailing Address - State:AR
Mailing Address - Zip Code:72902-1824
Mailing Address - Country:US
Mailing Address - Phone:479-709-7399
Mailing Address - Fax:479-709-7053
Practice Address - Street 1:5111 ROGERS AVE
Practice Address - Street 2:STE 40M
Practice Address - City:FORT SMITH
Practice Address - State:AR
Practice Address - Zip Code:72903-2047
Practice Address - Country:US
Practice Address - Phone:479-709-7440
Practice Address - Fax:479-709-7441
Is Sole Proprietor?:No
Enumeration Date:2005-10-06
Last Update Date:2008-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARC4289207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR105589001Medicaid
OK100073480AMedicaid
OK100073480AMedicaid
AR52572Medicare ID - Type Unspecified