Healthcare Provider Details

I. General information

NPI: 1609919836
Provider Name (Legal Business Name): JCWHIT P.A.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/15/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2713 S 74TH ST SUITE 408
FORT SMITH AR
72903-5170
US

IV. Provider business mailing address

2713 S 74TH ST SUITE 408
FORT SMITH AR
72903-5170
US

V. Phone/Fax

Practice location:
  • Phone: 479-484-5646
  • Fax:
Mailing address:
  • Phone: 479-484-5646
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberC-7165
License Number StateAR

VIII. Authorized Official

Name: DR. JOHN C WHITAKER
Title or Position: PHYSICIAN
Credential: M.D.
Phone: 479-484-5645