Healthcare Provider Details

I. General information

NPI: 1528278322
Provider Name (Legal Business Name): JOHN D PEMBERTON D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/23/2007
Last Update Date: 08/21/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4301 W MARKHAM ST # 523
LITTLE ROCK AR
72205-7101
US

IV. Provider business mailing address

4301 W MARKHAM ST # 523
LITTLE ROCK AR
72205-7101
US

V. Phone/Fax

Practice location:
  • Phone: 501-686-8000
  • Fax: 501-526-6780
Mailing address:
  • Phone: 501-686-8000
  • Fax: 501-526-6780

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207WX0200X
TaxonomyOphthalmic Plastic and Reconstructive Surgery Physician
License NumberE-6864
License Number StateAR
# 2
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License NumberE-6864
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: