Healthcare Provider Details

I. General information

NPI: 1225490899
Provider Name (Legal Business Name): JOHN B BOULDIN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/23/2016
Last Update Date: 04/30/2026
Certification Date: 04/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9601 BAPTIST HEALTH DR
LITTLE ROCK AR
72205-6321
US

IV. Provider business mailing address

11001 EXECUTIVE CENTER DR STE 200
LITTLE ROCK AR
72211-4393
US

V. Phone/Fax

Practice location:
  • Phone: 501-202-2300
  • Fax: 501-202-1449
Mailing address:
  • Phone: 501-812-7215
  • Fax: 501-812-7207

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberE-11849
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: