Healthcare Provider Details

I. General information

NPI: 1639674690
Provider Name (Legal Business Name): JULIE BETH GARDNER MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/29/2018
Last Update Date: 09/27/2024
Certification Date: 09/27/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1703 S WHITEHEAD DR
DE WITT AR
72042-2911
US

IV. Provider business mailing address

11001 EXECUTIVE CENTER DR STE 200
LITTLE ROCK AR
72211-4393
US

V. Phone/Fax

Practice location:
  • Phone: 870-946-0300
  • Fax: 870-946-0303
Mailing address:
  • Phone: 870-946-0300
  • Fax: 870-946-0303

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberE-15010
License Number StateAR
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberE-15010
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: