Provider Demographics
NPI:1821074592
Name:FENDLEY, JACK T (MD)
Entity Type:Individual
Prefix:DR
First Name:JACK
Middle Name:T
Last Name:FENDLEY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:11001 EXECUTIVE CENTER DR STE 200
Mailing Address - Street 2:
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72211-4393
Mailing Address - Country:US
Mailing Address - Phone:501-812-7215
Mailing Address - Fax:501-812-7207
Practice Address - Street 1:3500 SPRINGHILL DR STE 100
Practice Address - Street 2:
Practice Address - City:NORTH LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72117-2949
Practice Address - Country:US
Practice Address - Phone:501-955-5589
Practice Address - Fax:501-955-5960
Is Sole Proprietor?:No
Enumeration Date:2005-12-15
Last Update Date:2018-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARC4596207Q00000X, 207QA0505X, 207QG0300X, 207RE0101X, 207RG0300X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult Medicine
No207QG0300XAllopathic & Osteopathic PhysiciansFamily MedicineGeriatric Medicine
No207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & Metabolism
No207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR0420289OtherUNITED HEALTHCARE ID
AR110190362OtherRR MCARE PROVIDER ID
AR11306000000OtherQUALCHOICE PROVIDER ID
AR106701001Medicaid
AR4234056OtherAETNA PROVIDER ID
AR110190362OtherRR MCARE PROVIDER ID
AR106701001Medicaid