Provider Demographics
NPI:1518961580
Name:PHILLIPS, JOHN KENNETH (MD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:KENNETH
Last Name:PHILLIPS
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 1960
Mailing Address - Street 2:PO BOX 1960
Mailing Address - City:JONESBORO
Mailing Address - State:AR
Mailing Address - Zip Code:72403-1960
Mailing Address - Country:US
Mailing Address - Phone:870-936-8000
Mailing Address - Fax:870-936-1043
Practice Address - Street 1:3024 STADIUM BLVD
Practice Address - Street 2:
Practice Address - City:JONESBORO
Practice Address - State:AR
Practice Address - Zip Code:72401-7415
Practice Address - Country:US
Practice Address - Phone:870-934-5113
Practice Address - Fax:870-392-3608
Is Sole Proprietor?:No
Enumeration Date:2005-06-08
Last Update Date:2016-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARE01292085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO208891804Medicaid
AR129236001Medicaid
MO208891804Medicaid
5K021Medicare ID - Type Unspecified