Provider Demographics
NPI:1619046679
Name:JIMMERSON, ROBERT TYRAY II (MD)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:TYRAY
Last Name:JIMMERSON
Suffix:II
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 1:500 S UNIVERSITY AVE
Mailing Address - Street 2:SUITE 515
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72205-5306
Mailing Address - Country:US
Mailing Address - Phone:501-569-9961
Mailing Address - Fax:501-400-8649
Practice Address - Street 1:500 S UNIVERSITY AVE
Practice Address - Street 2:SUITE 515
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72205-5306
Practice Address - Country:US
Practice Address - Phone:501-569-9961
Practice Address - Fax:501-400-8649
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-06
Last Update Date:2014-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARE-1845207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR5K890OtherBCBS
18321000000OtherQUAL CHOICE
AR080158974OtherPALMETTOGBA
2451550OtherAETNA
AR135241001Medicaid
2717169OtherCIGNA
18321000000OtherQUAL CHOICE
AR5K890Medicare PIN