Basic Information
| Provider Information | |||||||||
| NPI: | 1003802828 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CONOVER | ||||||||
| FirstName: | RANDY | ||||||||
| MiddleName: | |||||||||
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| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 34 | ||||||||
| Address2: | |||||||||
| City: | CENTERTON | ||||||||
| State: | AR | ||||||||
| PostalCode: | 727190034 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4797950426 | ||||||||
| FaxNumber: | 4797950425 | ||||||||
| Practice Location | |||||||||
| Address1: | 101 SUN MEADOW DR | ||||||||
| Address2: | |||||||||
| City: | CENTERTON | ||||||||
| State: | AR | ||||||||
| PostalCode: | 727199610 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4797950426 | ||||||||
| FaxNumber: | 4797950425 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/27/2005 | ||||||||
| LastUpdateDate: | 09/03/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/03/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | E2837 | AR | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 143769003 | 05 | AR | MEDICAID |