Healthcare Provider Details

I. General information

NPI: 1366454209
Provider Name (Legal Business Name): SHANE R SPEIGHTS D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/12/2006
Last Update Date: 05/09/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

225 E JACKSON AVE
JONESBORO AR
72401-3119
US

IV. Provider business mailing address

506 HUNTCLIFF DR
JONESBORO AR
72404-9561
US

V. Phone/Fax

Practice location:
  • Phone: 870-207-4423
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207PE0004X
TaxonomyEmergency Medical Services (Emergency Medicine) Physician
License NumberE-4562
License Number StateAR
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberE-4562
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: