Healthcare Provider Details

I. General information

NPI: 1033437538
Provider Name (Legal Business Name): JORDAN WEAVER, M.D.,PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/07/2010
Last Update Date: 09/22/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1995 HARRISON ST
BATESVILLE AR
72501-7309
US

IV. Provider business mailing address

1995 HARRISON ST
BATESVILLE AR
72501-7309
US

V. Phone/Fax

Practice location:
  • Phone: 870-793-2540
  • Fax:
Mailing address:
  • Phone: 870-793-2540
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMC-2756
License Number StateAR

VIII. Authorized Official

Name: MICHAEL J WEAVER
Title or Position: PRESIDENT
Credential: MD
Phone: 870-793-2540