Healthcare Provider Details

I. General information

NPI: 1033106505
Provider Name (Legal Business Name): JESSE E CLANTON M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/30/2005
Last Update Date: 07/29/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2302 COLLEGE AVE
CONWAY AR
72034-6297
US

IV. Provider business mailing address

2302 COLLEGE AVE
CONWAY AR
72034-6297
US

V. Phone/Fax

Practice location:
  • Phone: 501-513-5793
  • Fax: 501-513-5417
Mailing address:
  • Phone: 501-513-5793
  • Fax: 501-513-5417

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberC5274
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: