Provider Demographics
NPI:1902245889
Name:JEAN, GRETA (MD)
Entity Type:Individual
Prefix:
First Name:GRETA
Middle Name:
Last Name:JEAN
Suffix:
Gender:F
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:PO BOX 497
Mailing Address - Street 2:
Mailing Address - City:AUGUSTA
Mailing Address - State:AR
Mailing Address - Zip Code:72006-0497
Mailing Address - Country:US
Mailing Address - Phone:870-347-2534
Mailing Address - Fax:870-347-1235
Practice Address - Street 1:3057 SPRINGDALE AVE
Practice Address - Street 2:
Practice Address - City:SPRINGDALE
Practice Address - State:AR
Practice Address - Zip Code:72762-4346
Practice Address - Country:US
Practice Address - Phone:479-756-1699
Practice Address - Fax:479-756-1693
Is Sole Proprietor?:Yes
Enumeration Date:2013-06-24
Last Update Date:2021-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
ARE-9524207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR217423001Medicaid