Provider Demographics
NPI:1336131887
Name:WITHERSPOON, JOHN BRADLEY (OD)
Entity Type:Individual
Prefix:MR
First Name:JOHN
Middle Name:BRADLEY
Last Name:WITHERSPOON
Suffix:
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 1:1155 HWY 65 NORTH
Mailing Address - Street 2:
Mailing Address - City:CONWAY
Mailing Address - State:AR
Mailing Address - Zip Code:72032
Mailing Address - Country:US
Mailing Address - Phone:501-328-9500
Mailing Address - Fax:501-328-5148
Practice Address - Street 1:1155 HWY 65 NORTH
Practice Address - Street 2:
Practice Address - City:CONWAY
Practice Address - State:AR
Practice Address - Zip Code:72032
Practice Address - Country:US
Practice Address - Phone:501-328-9500
Practice Address - Fax:501-328-5148
Is Sole Proprietor?:No
Enumeration Date:2005-08-19
Last Update Date:2010-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR2272152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR106399722Medicaid
AR49404Medicare ID - Type Unspecified
AR106399722Medicaid