Provider Demographics
NPI:1184711236
Name:KINCANNON, JAY (MD)
Entity type:Individual
Prefix:
First Name:JAY
Middle Name:
Last Name:KINCANNON
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 1:1 CHILDRENS WAY # 653
Mailing Address - Street 2:
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72202-3500
Mailing Address - Country:US
Mailing Address - Phone:501-364-1100
Mailing Address - Fax:501-526-5148
Practice Address - Street 1:1 CHILDRENS WAY # 653
Practice Address - Street 2:
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72202-3500
Practice Address - Country:US
Practice Address - Phone:501-364-1100
Practice Address - Fax:501-526-5148
Is Sole Proprietor?:No
Enumeration Date:2006-10-09
Last Update Date:2011-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARC-6844207NP0225X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207NP0225XAllopathic & Osteopathic PhysiciansDermatologyPediatric Dermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR119266001Medicaid
AR370005986OtherRAILROAD MEDICARE
AR5AJ06Medicare PIN
E85452Medicare UPIN
54609Medicare PIN