Provider Demographics
NPI:1689692360
Name:MEDLOCK, JEFFREY A (MD)
Entity Type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:A
Last Name:MEDLOCK
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 1:937 HIGHWAY 64 EAST
Mailing Address - Street 2:
Mailing Address - City:ALMA
Mailing Address - State:AR
Mailing Address - Zip Code:72921
Mailing Address - Country:US
Mailing Address - Phone:479-632-3855
Mailing Address - Fax:479-632-0296
Practice Address - Street 1:937 HIGHWAY 64 EAST
Practice Address - Street 2:
Practice Address - City:ALMA
Practice Address - State:AR
Practice Address - Zip Code:72921
Practice Address - Country:US
Practice Address - Phone:479-632-3855
Practice Address - Fax:479-632-0296
Is Sole Proprietor?:No
Enumeration Date:2006-07-18
Last Update Date:2016-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARE-0205207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
080179030OtherRR MEDICARE
AR129661001Medicaid
AR5J557Medicare ID - Type Unspecified
AR129661001Medicaid