Provider Demographics
NPI:1487812392
Name:DEREK S LONG OD INC
Entity type:Organization
Organization Name:DEREK S LONG OD INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:DEREK
Authorized Official - Middle Name:S
Authorized Official - Last Name:LONG
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:501-803-3937
Mailing Address - Street 1:115 AUDUBON DR STE 8
Mailing Address - Street 2:
Mailing Address - City:MAUMELLE
Mailing Address - State:AR
Mailing Address - Zip Code:72113-7409
Mailing Address - Country:US
Mailing Address - Phone:501-803-3937
Mailing Address - Fax:501-803-3962
Practice Address - Street 1:4425 CENTRAL AVE STE B
Practice Address - Street 2:
Practice Address - City:HOT SPRINGS
Practice Address - State:AR
Practice Address - Zip Code:71913-7297
Practice Address - Country:US
Practice Address - Phone:501-525-0501
Practice Address - Fax:501-525-0628
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-28
Last Update Date:2010-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR2547152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR180260722Medicaid
AR180260722Medicaid