1487812392 NPI number — DEREK S LONG OD INC

Table of content: (NPI 1487812392)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1487812392 NPI number — DEREK S LONG OD INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DEREK S LONG OD INC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1487812392
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/24/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
115 AUDUBON DR STE 8
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MAUMELLE
Provider Business Mailing Address State Name:
AR
Provider Business Mailing Address Postal Code:
72113-7409
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
501-803-3937
Provider Business Mailing Address Fax Number:
501-803-3962

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4425 CENTRAL AVE STE B
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HOT SPRINGS
Provider Business Practice Location Address State Name:
AR
Provider Business Practice Location Address Postal Code:
71913-7297
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
501-525-0501
Provider Business Practice Location Address Fax Number:
501-525-0628
Provider Enumeration Date:
05/28/2008

Additional Information

Authorized Official

Authorized Official Last Name:
LONG
Authorized Official First Name:
DEREK
Authorized Official Middle Name:
S
Authorized Official Title or Position:
DOCTOR
Authorized Official Telephone Number:
501-803-3937

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , with the licence number:  2547 , registered in the state of AR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 180260722 , issued by the state of ( AR ) . This identifiers is of the category "MEDICAID".




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