Healthcare Provider Details

I. General information

NPI: 1669459905
Provider Name (Legal Business Name): GERALD S STIPANUK MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/28/2005
Last Update Date: 07/12/2024
Certification Date: 07/12/2024
Deactivation Date: 11/01/2017
Reactivation Date: 11/21/2017

III. Provider practice location address

1007 WINDOVER RD # 6009
JONESBORO AR
72401-6007
US

IV. Provider business mailing address

1007 WINDOVER RD # 6009
JONESBORO AR
72401-6007
US

V. Phone/Fax

Practice location:
  • Phone: 870-520-6473
  • Fax:
Mailing address:
  • Phone: 870-204-0534
  • Fax: 731-235-0559

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number29939
License Number StateTN
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberE-7145
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: