Healthcare Provider Details

I. General information

NPI: 1124472410
Provider Name (Legal Business Name): JORDAN MATTHEW WALTERS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/22/2016
Last Update Date: 06/03/2025
Certification Date: 06/03/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

550 CLUB LN STE 1
CONWAY AR
72034-3681
US

IV. Provider business mailing address

PO BOX 9662
CONWAY AR
72033-9662
US

V. Phone/Fax

Practice location:
  • Phone: 501-329-1510
  • Fax: 501-513-0478
Mailing address:
  • Phone: 501-852-1363
  • Fax: 501-852-1364

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License NumberE-14425
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: