Healthcare Provider Details

I. General information

NPI: 1407840101
Provider Name (Legal Business Name): JAY DANIEL GEOGHAGAN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/08/2005
Last Update Date: 10/04/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3343 SPRINGHILL DR SUITE 1035
NORTH LITTLE ROCK AR
72117-2929
US

IV. Provider business mailing address

3343 SPRINGHILL DR STE 1035
NORTH LITTLE ROCK AR
72117-2929
US

V. Phone/Fax

Practice location:
  • Phone: 501-975-7676
  • Fax: 501-537-0206
Mailing address:
  • Phone: 501-975-7676
  • Fax: 501-537-0206

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License NumberME88853
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License NumberE-2040
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: