Provider Demographics
NPI:1164499935
Name:BOZEMAN, JIMMY G (MD)
Entity Type:Individual
Prefix:DR
First Name:JIMMY
Middle Name:G
Last Name:BOZEMAN
Suffix:
Gender:M
Credentials:MD
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 517
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:AR
Mailing Address - Zip Code:72576-0517
Mailing Address - Country:US
Mailing Address - Phone:870-895-6096
Mailing Address - Fax:870-895-3833
Practice Address - Street 1:507 N MAIN ST
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:AR
Practice Address - Zip Code:72576-9449
Practice Address - Country:US
Practice Address - Phone:870-895-2541
Practice Address - Fax:870-895-2957
Is Sole Proprietor?:No
Enumeration Date:2006-03-01
Last Update Date:2017-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARC-4579208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO200621605OtherMEDICAID
AR50573OtherBLUE CROSS BLUE SHIELD
AR102258001Medicaid
AR127770000OtherQUALCHOICE
AR50573Medicare ID - Type Unspecified
AR50573OtherBLUE CROSS BLUE SHIELD