Healthcare Provider Details

I. General information

NPI: 1861478232
Provider Name (Legal Business Name): COLLEGE PARK FAMILY CLINIC PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/19/2005
Last Update Date: 09/11/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2511-A COLLEGE AVE
CONWAY AR
72034
US

IV. Provider business mailing address

2511-A COLLEGE AVE
CONWAY AR
72034
US

V. Phone/Fax

Practice location:
  • Phone: 501-327-6041
  • Fax: 501-327-6043
Mailing address:
  • Phone: 501-327-6041
  • Fax: 501-327-6043

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberC6340
License Number StateAR
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberC6340
License Number StateAR
# 3
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberC6340
License Number StateAR

VIII. Authorized Official

Name: GIL E JOHNSON
Title or Position: CEO PRESIDENT
Credential: MD
Phone: 501-327-6041