Healthcare Provider Details

I. General information

NPI: 1184192510
Provider Name (Legal Business Name): JACK ZEPEDA MD, MPH
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/03/2018
Last Update Date: 05/17/2022
Certification Date: 01/20/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1301 S E ST
FORT SMITH AR
72901-4716
US

IV. Provider business mailing address

1005 MAR WALT DR
FORT WALTON BEACH FL
32547-6707
US

V. Phone/Fax

Practice location:
  • Phone: 479-785-2431
  • Fax:
Mailing address:
  • Phone: 850-863-8100
  • Fax: 850-863-8548

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number2018036941
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberE-13916
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: