Provider Demographics
NPI:1124195698
Name:URBAN, JOHN C (DO)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:C
Last Name:URBAN
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 130
Mailing Address - Street 2:
Mailing Address - City:RATCLIFF
Mailing Address - State:AR
Mailing Address - Zip Code:72951-0130
Mailing Address - Country:US
Mailing Address - Phone:479-635-5300
Mailing Address - Fax:479-635-2010
Practice Address - Street 1:9755 W STATE HIGHWAY 22
Practice Address - Street 2:
Practice Address - City:RATCLIFF
Practice Address - State:AR
Practice Address - Zip Code:72951-9000
Practice Address - Country:US
Practice Address - Phone:479-635-5300
Practice Address - Fax:479-635-2010
Is Sole Proprietor?:No
Enumeration Date:2006-11-29
Last Update Date:2011-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101013179207Q00000X
ARE-6881207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4794578Medicaid
AR186063003Medicaid
MIH96111Medicare UPIN
5AH76Medicare PIN
AR186063003Medicaid