Provider Demographics
NPI:1871685065
Name:NUTT, JERRY RANDALL JR (OD)
Entity Type:Individual
Prefix:MR
First Name:JERRY
Middle Name:RANDALL
Last Name:NUTT
Suffix:JR
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:515 CASH RD SW
Mailing Address - Street 2:
Mailing Address - City:CAMDEN
Mailing Address - State:AR
Mailing Address - Zip Code:71701-3706
Mailing Address - Country:US
Mailing Address - Phone:870-836-2525
Mailing Address - Fax:870-836-7252
Practice Address - Street 1:515 CASH RD SW
Practice Address - Street 2:
Practice Address - City:CAMDEN
Practice Address - State:AR
Practice Address - Zip Code:71701-3706
Practice Address - Country:US
Practice Address - Phone:870-836-2525
Practice Address - Fax:870-836-7252
Is Sole Proprietor?:No
Enumeration Date:2006-09-28
Last Update Date:2011-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR2570152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR49958OtherARK BCBS
AR49958OtherBLUE CARD/AR BCBS
AR49958OtherARK BCBS MEDIPAK
AR49958OtherBLUE ADVANTAGE
AR180852722Medicaid
AR49958OtherMEDIPAK ADVANTAGE
AR49958OtherHEALTH ADVANTAGE
AR49958OtherARK BCBS