Healthcare Provider Details

I. General information

NPI: 1295653442
Provider Name (Legal Business Name): WILLIAM JOHNSON INTERN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/07/2026
Last Update Date: 07/07/2026
Certification Date: 07/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5200 KAVANAUGH BLVD
LITTLE ROCK AR
72207-4609
US

IV. Provider business mailing address

18 COOLWOOD DR
LITTLE ROCK AR
72202-2122
US

V. Phone/Fax

Practice location:
  • Phone: 501-664-3844
  • Fax:
Mailing address:
  • Phone: 479-806-6646
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License NumberPI23569
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: