Healthcare Provider Details

I. General information

NPI: 1346289709
Provider Name (Legal Business Name): GASTROENTEROLOGY ASSOCIATES OF SOUTHEAST ARKANSAS, P.A.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/04/2006
Last Update Date: 03/24/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1609 W 40TH AVE SUITE 312
PINE BLUFF AR
71603-6329
US

IV. Provider business mailing address

1609 W 40TH AVE SUITE 312
PINE BLUFF AR
71603-6329
US

V. Phone/Fax

Practice location:
  • Phone: 870-534-3344
  • Fax: 870-534-3517
Mailing address:
  • Phone: 870-534-3344
  • Fax: 870-534-3517

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM2500X
TaxonomyMedical Specialty Clinic/Center
License NumberC5353
License Number StateAR

VIII. Authorized Official

Name: DR. O T GORDON JR.
Title or Position: PRESIDENT
Credential: M.D.
Phone: 870-534-3344