Basic Information
Provider Information | |||||||||
NPI: | 1790190296 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | RAMOS RAMIREZ | ||||||||
FirstName: | MANUEL | ||||||||
MiddleName: | DE JESUS | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 1960 | ||||||||
Address2: |   | ||||||||
City: | JONESBORO | ||||||||
State: | AR | ||||||||
PostalCode: | 724031960 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8709368000 | ||||||||
FaxNumber: | 8709343626 | ||||||||
Practice Location | |||||||||
Address1: | 4802 E JOHNSON AVE | ||||||||
Address2: |   | ||||||||
City: | JONESBORO | ||||||||
State: | AR | ||||||||
PostalCode: | 724058413 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8709368000 | ||||||||
FaxNumber: | 8709343626 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/24/2014 | ||||||||
LastUpdateDate: | 07/16/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 07/16/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | S0067 | TX | N |   | Allopathic & Osteopathic Physicians | Internal Medicine |   | 207RC0200X | E-14503 | AR | N |   | Allopathic & Osteopathic Physicians | Internal Medicine | Critical Care Medicine | 207RP1001X | E-14503 | AR | Y |   | Allopathic & Osteopathic Physicians | Internal Medicine | Pulmonary Disease |
ID Information
ID | Type | State | Issuer | Description | S0067 | 01 | TX | TEXAS MEDICAL BOARD - PHYSICIAN FULL PERMIT | OTHER |