Provider Demographics
NPI:1881873826
Name:NUCKOLLS, J. W (MD)
Entity type:Individual
Prefix:
First Name:J.
Middle Name:W
Last Name:NUCKOLLS
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 1:1801 W 40TH AVE
Mailing Address - Street 2:
Mailing Address - City:PINE BLUFF
Mailing Address - State:AR
Mailing Address - Zip Code:71603-6940
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:
Practice Address - City:PINE BLUFF
Practice Address - State:AR
Practice Address - Zip Code:71603-6940
Practice Address - Country:US
Practice Address - Phone:870-541-0222
Practice Address - Fax:870-541-0315
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-26
Last Update Date:2007-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARR2177174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
E05073Medicare UPIN
53847Medicare PIN