Provider Demographics
NPI:1699865857
Name:NGENGWE, RAPHAEL N (MD)
Entity type:Individual
Prefix:
First Name:RAPHAEL
Middle Name:N
Last Name:NGENGWE
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 1:201 E OAK AVE
Mailing Address - Street 2:
Mailing Address - City:JONESBORO
Mailing Address - State:AR
Mailing Address - Zip Code:72401-4163
Mailing Address - Country:US
Mailing Address - Phone:870-935-6729
Mailing Address - Fax:870-935-6729
Practice Address - Street 1:201 E OAK AVE
Practice Address - Street 2:
Practice Address - City:JONESBORO
Practice Address - State:AR
Practice Address - Zip Code:72401-4163
Practice Address - Country:US
Practice Address - Phone:870-935-6729
Practice Address - Fax:870-268-4478
Is Sole Proprietor?:No
Enumeration Date:2006-10-16
Last Update Date:2023-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARE9433207RC0001X
SD14665207RC0000X
OH35088468207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Yes207RC0001XAllopathic & Osteopathic PhysiciansInternal MedicineClinical Cardiac Electrophysiology
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR1699865857Medicaid
ARE9433OtherSTATE MEDICAL LICENSE
466348YJLRMedicare UPIN