Provider Demographics
NPI:1376834101
Name:COON, JEFFERYDON LEE (D O)
Entity Type:Individual
Prefix:DR
First Name:JEFFERYDON
Middle Name:LEE
Last Name:COON
Suffix:
Gender:M
Credentials:D O
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2801 MEDICAL CENTER DR
Mailing Address - Street 2:
Mailing Address - City:POCAHONTAS
Mailing Address - State:AR
Mailing Address - Zip Code:72455-9436
Mailing Address - Country:US
Mailing Address - Phone:870-892-6000
Mailing Address - Fax:
Practice Address - Street 1:2801 MEDICAL CENTER DR
Practice Address - Street 2:
Practice Address - City:POCAHONTAS
Practice Address - State:AR
Practice Address - Zip Code:72455-9436
Practice Address - Country:US
Practice Address - Phone:870-892-6000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-04-27
Last Update Date:2017-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARE-9674207R00000X
VA0116025994207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ARPD09494OtherARKANSAS PHARMACIST LICENSE
ARE-9674OtherARKANSAS MEDICAL LICENSE