Provider Demographics
NPI:1366484479
Name:GILLESPIE, JOHN N (MD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:N
Last Name:GILLESPIE
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 1:1235 CAMBRIDGE RD
Mailing Address - Street 2:
Mailing Address - City:BENTON
Mailing Address - State:AR
Mailing Address - Zip Code:72019-2378
Mailing Address - Country:US
Mailing Address - Phone:501-765-8813
Mailing Address - Fax:
Practice Address - Street 1:2711 E PARKWAY DR
Practice Address - Street 2:
Practice Address - City:RUSSELLVILLE
Practice Address - State:AR
Practice Address - Zip Code:72802-2006
Practice Address - Country:US
Practice Address - Phone:479-968-7302
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-12
Last Update Date:2019-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARE2388207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR138820001Medicaid
180046096OtherRAILROAD MEDICARE