Healthcare Provider Details

I. General information

NPI: 1164499935
Provider Name (Legal Business Name): JIMMY G BOZEMAN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/01/2006
Last Update Date: 02/01/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

507 N MAIN ST
SALEM AR
72576-9449
US

IV. Provider business mailing address

PO BOX 517
SALEM AR
72576-0517
US

V. Phone/Fax

Practice location:
  • Phone: 870-895-2541
  • Fax: 870-895-2957
Mailing address:
  • Phone: 870-895-6096
  • Fax: 870-895-3833

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License NumberC-4579
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: