=====================================================
General NPI Number Information
=====================================================
NPI Number | 1669459905
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | GERALD S STIPANUK MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/28/2005
-----------------------------------------------------
Last Update Date | 07/12/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1007 WINDOVER RD # 6009
-----------------------------------------------------
City | JONESBORO
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 72401-6007
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 870-520-6473
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1007 WINDOVER RD # 6009
-----------------------------------------------------
City | JONESBORO
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 72401-6007
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 870-204-0534
-----------------------------------------------------
Fax | 731-235-0559
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207R00000X
-----------------------------------------------------
Taxonomy Name | Internal Medicine Physician
-----------------------------------------------------
License Number | 29939
-----------------------------------------------------
License Number State | TN
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207R00000X
-----------------------------------------------------
Taxonomy Name | Internal Medicine Physician
-----------------------------------------------------
License Number | E-7145
-----------------------------------------------------
License Number State | AR
-----------------------------------------------------