Provider Demographics
NPI:1457747297
Name:WANTULOK, NATASHA MARIE (MD)
Entity type:Individual
Prefix:MRS
First Name:NATASHA
Middle Name:MARIE
Last Name:WANTULOK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:NATASHA
Other - Middle Name:MARIE
Other - Last Name:DIFANI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2901 MEDICAL CENTER DR
Mailing Address - Street 2:
Mailing Address - City:POCAHONTAS
Mailing Address - State:AR
Mailing Address - Zip Code:72455-9438
Mailing Address - Country:US
Mailing Address - Phone:870-892-4467
Mailing Address - Fax:870-892-4407
Practice Address - Street 1:2901 MEDICAL CENTER DR
Practice Address - Street 2:
Practice Address - City:POCAHONTAS
Practice Address - State:AR
Practice Address - Zip Code:72455-9438
Practice Address - Country:US
Practice Address - Phone:870-892-4467
Practice Address - Fax:870-892-4407
Is Sole Proprietor?:No
Enumeration Date:2015-04-08
Last Update Date:2018-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARE-10809207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR229157001Medicaid