Provider Demographics
NPI:1386623056
Name:CARMACK, JONI L (MD)
Entity type:Individual
Prefix:
First Name:JONI
Middle Name:L
Last Name:CARMACK
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 1:1004 E BRYAN AVE
Mailing Address - Street 2:
Mailing Address - City:SAPULPA
Mailing Address - State:OK
Mailing Address - Zip Code:74066-4513
Mailing Address - Country:US
Mailing Address - Phone:918-748-7557
Mailing Address - Fax:
Practice Address - Street 1:EAST MAIN & SOUTH 20TH STREET
Practice Address - Street 2:
Practice Address - City:VAN BUREN
Practice Address - State:AR
Practice Address - Zip Code:72957
Practice Address - Country:US
Practice Address - Phone:479-474-3401
Practice Address - Fax:479-471-4388
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-01-11
Last Update Date:2017-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARE-3151207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR5M145OtherBLUECROSS BLUESHIELD
AR146400001Medicaid
AR5M145Medicare ID - Type Unspecified
AR146400001Medicaid