Basic Information
| Provider Information | |||||||||
| NPI: | 1891727855 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | IRONSIDE | ||||||||
| FirstName: | JOHN | ||||||||
| MiddleName: | BRETT | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 10001 LILE DR | ||||||||
| Address2: | |||||||||
| City: | LITTLE ROCK | ||||||||
| State: | AR | ||||||||
| PostalCode: | 722056217 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5012278000 | ||||||||
| FaxNumber: | 5012277362 | ||||||||
| Practice Location | |||||||||
| Address1: | 10001 LILE DR | ||||||||
| Address2: | |||||||||
| City: | LITTLE ROCK | ||||||||
| State: | AR | ||||||||
| PostalCode: | 722056217 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5012278000 | ||||||||
| FaxNumber: | 5012277362 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/07/2006 | ||||||||
| LastUpdateDate: | 04/17/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084N0400X | C8268 | AR | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology |
ID Information
| ID | Type | State | Issuer | Description | 686523 | 01 | AR | MEDICARE ID# FOR CHI ST. VINCENT LITTLE ROCK DIAGNOSTIC CLINIC | OTHER | 129100001 | 05 | AR | MEDICAID |