Healthcare Provider Details

I. General information

NPI: 1639142284
Provider Name (Legal Business Name): JERRY N CAVANEAU M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/13/2006
Last Update Date: 05/28/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4411 HIGHWAY 5 N
BRYANT AR
72022-7005
US

IV. Provider business mailing address

4411 HIGHWAY 5 N
BRYANT AR
72022-7005
US

V. Phone/Fax

Practice location:
  • Phone: 501-847-0289
  • Fax:
Mailing address:
  • Phone: 501-847-0289
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberE2550
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: