MEDICARE: DR. JENNINGS R BOYETTE MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207YS0123X	Facial Plastic Surgery Physician	MD.205264	LA
2	390200000X	Student in an Organized Health Care Education/Training Program		AR
3	207YX0007X	Plastic Surgery within the Head & Neck (Otolaryngology) Physician	E-7894	AR

General Provider Information

NPI Number	:	1922216084
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JENNINGS R BOYETTE MD

Provider Business Mailing Address
First Line	:	PO BOX 23037
Second Line	:
City	:	LITTLE ROCK
State	:	AR
Zip	:	72221-3037
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	11412 HURON LN
Second Line	:
City	:	LITTLE ROCK
State	:	AR
Zip	:	72211-1847
Country	:	US
Telephone Number	:	501-302-1402
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/20/2007
Last Update Date	:	01/12/2023

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