Provider Demographics
NPI:1093786170
Name:ST. CLAIR, JOHN T JR
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:T
Last Name:ST. CLAIR
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:800 S CHURCH ST
Mailing Address - Street 2:SUITE 302
Mailing Address - City:JONESBORO
Mailing Address - State:AR
Mailing Address - Zip Code:72401-4176
Mailing Address - Country:US
Mailing Address - Phone:870-935-3990
Mailing Address - Fax:870-935-0871
Practice Address - Street 1:800 S CHURCH ST
Practice Address - Street 2:SUITE 302
Practice Address - City:JONESBORO
Practice Address - State:AR
Practice Address - Zip Code:72401-4176
Practice Address - Country:US
Practice Address - Phone:870-935-3990
Practice Address - Fax:870-935-0871
Is Sole Proprietor?:No
Enumeration Date:2006-01-27
Last Update Date:2012-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARR1950207VG0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR770138701OtherEDS BREASTCARE
AR54635OtherBLUE CROSS
3831645OtherCIGNA
AS0140129OtherHUMANA TRICARE
AR12874000040OtherQUALCHOICE
AR101682001Medicaid
AR160027630OtherMEDICARE RAILROAD CARRIER
AR101682001Medicaid
AR546356911Medicare PIN