Basic Information
| Provider Information | |||||||||
| NPI: | 1740356153 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LINDSAY | ||||||||
| FirstName: | JASON | ||||||||
| MiddleName: | TEAGUE | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 15 GREEN VALLEY DR | ||||||||
| Address2: | |||||||||
| City: | MOUNTAIN HOME | ||||||||
| State: | AR | ||||||||
| PostalCode: | 726538102 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8707010490 | ||||||||
| FaxNumber: | 8707010491 | ||||||||
| Practice Location | |||||||||
| Address1: | 15 GREEN VALLEY DR | ||||||||
| Address2: | |||||||||
| City: | MOUNTAIN HOME | ||||||||
| State: | AR | ||||||||
| PostalCode: | 726538102 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8707010490 | ||||||||
| FaxNumber: | 8707010491 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/28/2006 | ||||||||
| LastUpdateDate: | 06/09/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/09/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208800000X | E4783 | AR | Y | Allopathic & Osteopathic Physicians | Urology |
ID Information
| ID | Type | State | Issuer | Description | 167290001 | 05 | AR | MEDICAID | E4783 | 01 | AR | STATE LICENSE | OTHER |