Provider Demographics
NPI:1710126529
Name:BOYCE, JOHNNIE MACK (MD)
Entity Type:Individual
Prefix:DR
First Name:JOHNNIE
Middle Name:MACK
Last Name:BOYCE
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 1:104 HARRIS LANE
Mailing Address - Street 2:
Mailing Address - City:SPRINGDALE
Mailing Address - State:AR
Mailing Address - Zip Code:72764-2530
Mailing Address - Country:US
Mailing Address - Phone:479-751-0652
Mailing Address - Fax:
Practice Address - Street 1:104 HARRIS LANE
Practice Address - Street 2:
Practice Address - City:SPRINGDALE
Practice Address - State:AR
Practice Address - Zip Code:72764-2530
Practice Address - Country:US
Practice Address - Phone:479-751-0652
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-02-18
Last Update Date:2009-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARC-2676(ACTIVE STATUS207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR117073001Medicaid
AR117073001Medicaid