Healthcare Provider Details

I. General information

NPI: 1922687649
Provider Name (Legal Business Name): JOSEPH AARON KOON II
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/08/2021
Last Update Date: 07/15/2024
Certification Date: 07/15/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

819 W CARPENTER ST
BENTON AR
72015-3349
US

IV. Provider business mailing address

14221 PARKSIDE DR
LITTLE ROCK AR
72211-3036
US

V. Phone/Fax

Practice location:
  • Phone: 501-778-8264
  • Fax: 501-778-7360
Mailing address:
  • Phone: 501-920-4624
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberE-16850
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: