Provider Demographics
NPI:1245235605
Name:JEAN-LOUIS, GOTTFRIED G (MD)
Entity Type:Individual
Prefix:MR
First Name:GOTTFRIED
Middle Name:G
Last Name:JEAN-LOUIS
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 1:2708 RIFE MEDICAL LN STE 200
Mailing Address - Street 2:
Mailing Address - City:ROGERS
Mailing Address - State:AR
Mailing Address - Zip Code:72758-1452
Mailing Address - Country:US
Mailing Address - Phone:479-338-3080
Mailing Address - Fax:479-338-3089
Practice Address - Street 1:2708 RIFE MEDICAL LN STE 200
Practice Address - Street 2:
Practice Address - City:ROGERS
Practice Address - State:AR
Practice Address - Zip Code:72758-1452
Practice Address - Country:US
Practice Address - Phone:479-338-3080
Practice Address - Fax:479-338-3089
Is Sole Proprietor?:No
Enumeration Date:2005-06-14
Last Update Date:2011-12-13
Deactivation Date:2006-03-17
Deactivation Code:
Reactivation Date:2006-03-23
Provider Licenses
StateLicense IDTaxonomies
ARE-69292084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR184750001Medicaid
AR5AK04Medicare PIN