Provider Demographics
NPI:1922216084
Name:BOYETTE, JENNINGS R (MD)
Entity Type:Individual
Prefix:DR
First Name:JENNINGS
Middle Name:R
Last Name:BOYETTE
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:PO BOX 23037
Mailing Address - Street 2:
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72221-3037
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:11412 HURON LN
Practice Address - Street 2:
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72211-1847
Practice Address - Country:US
Practice Address - Phone:501-302-1402
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-20
Last Update Date:2023-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAMD.205264207YS0123X
AR390200000X
ARE-7894207YX0007X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207YX0007XAllopathic & Osteopathic PhysiciansOtolaryngologyPlastic Surgery within the Head & Neck
No207YS0123XAllopathic & Osteopathic PhysiciansOtolaryngologyFacial Plastic Surgery
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program