Healthcare Provider Details

I. General information

NPI: 1407040488
Provider Name (Legal Business Name): JEFFREY COWAN ELLISON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/01/2007
Last Update Date: 11/02/2021
Certification Date: 11/02/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3344 N FUTRALL DR
FAYETTEVILLE AR
72703-4057
US

IV. Provider business mailing address

PO BOX 1523
FAYETTEVILLE AR
72702-1523
US

V. Phone/Fax

Practice location:
  • Phone: 479-521-8200
  • Fax: 479-582-7310
Mailing address:
  • Phone: 479-571-6038
  • Fax: 479-582-0222

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License NumberE-6356
License Number StateAR
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number25527
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: