1700194990 NPI number — JOHN B WITHERSPOON OPTOMETRIC PHYSICIAN LTD

Table of content: DEBORAH JO MCBRIDE NP (NPI 1114905205)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1700194990 NPI number — JOHN B WITHERSPOON OPTOMETRIC PHYSICIAN LTD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
JOHN B WITHERSPOON OPTOMETRIC PHYSICIAN LTD
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1700194990
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/27/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1155 HWY 65 NORTH
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CONWAY
Provider Business Mailing Address State Name:
AR
Provider Business Mailing Address Postal Code:
72032
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
501-328-9500
Provider Business Mailing Address Fax Number:
501-328-5148

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
29 RIVER ROAD DR E
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MAYFLOWER
Provider Business Practice Location Address State Name:
AR
Provider Business Practice Location Address Postal Code:
72106-8409
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
501-328-9500
Provider Business Practice Location Address Fax Number:
501-328-5148
Provider Enumeration Date:
09/22/2010

Additional Information

Authorized Official

Authorized Official Last Name:
WITHERSPOON
Authorized Official First Name:
JOHN
Authorized Official Middle Name:
B
Authorized Official Title or Position:
OWNER/PHYSICIAN
Authorized Official Telephone Number:
501-328-9500

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , with the licence number:  2272 , registered in the state of AR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 106399722 , issued by the state of ( AR ) . This identifiers is of the category "MEDICAID".
  • Identifier: 5G617 . This is a "MEDICARE PTAN" identifier , issued by the state of ( AR ) . This identifiers is of the category "OTHER".




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