Healthcare Provider Details

I. General information

NPI: 1801035969
Provider Name (Legal Business Name): JEREMIAH SCOTT RUTHERFORD M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/13/2009
Last Update Date: 09/10/2026
Certification Date: 09/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1701 CLUB MANOR DR STE 2B
MAUMELLE AR
72113-7401
US

IV. Provider business mailing address

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

V. Phone/Fax

Practice location:
  • Phone: 501-851-7402
  • Fax: 501-851-4753
Mailing address:
  • Phone: 501-851-7402
  • Fax: 501-851-4753

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberE-10897
License Number StateAR
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number26821
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: