Provider Demographics
NPI:1750345575
Name:J. W NUCKOLLS MD
Entity type:Organization
Organization Name:J. W NUCKOLLS MD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:J.
Authorized Official - Middle Name:W
Authorized Official - Last Name:NUCKOLLS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:870-541-0222
Mailing Address - Street 1:1801 WEST 40TH
Mailing Address - Street 2:SUITE 1-C
Mailing Address - City:PINE BLUFF
Mailing Address - State:AR
Mailing Address - Zip Code:71603-6956
Mailing Address - Country:US
Mailing Address - Phone:870-541-0222
Mailing Address - Fax:870-541-0315
Practice Address - Street 1:1801 W 40TH AVE
Practice Address - Street 2:SUITE 1C
Practice Address - City:PINE BLUFF
Practice Address - State:AR
Practice Address - Zip Code:71603-6956
Practice Address - Country:US
Practice Address - Phone:870-541-0222
Practice Address - Fax:870-541-0315
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-17
Last Update Date:2007-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARR2177261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR53847Medicare ID - Type Unspecified
ARE05073Medicare UPIN