Provider Demographics
NPI:1154391514
Name:ABISEID, JOSE (MD)
Entity type:Individual
Prefix:
First Name:JOSE
Middle Name:
Last Name:ABISEID
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:PO BOX 1100
Mailing Address - Street 2:
Mailing Address - City:CLINTON
Mailing Address - State:AR
Mailing Address - Zip Code:72031-1100
Mailing Address - Country:US
Mailing Address - Phone:501-745-2800
Mailing Address - Fax:501-745-8864
Practice Address - Street 1:194 SHAKERAG RD
Practice Address - Street 2:
Practice Address - City:CLINTON
Practice Address - State:AR
Practice Address - Zip Code:72031
Practice Address - Country:US
Practice Address - Phone:501-745-2800
Practice Address - Fax:501-745-8864
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-26
Last Update Date:2011-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARN6056207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR106212001Medicaid
010055804Medicare PIN
AR106212001Medicaid
AR50011Medicare PIN