Provider Demographics
NPI:1043412067
Name:DEREK S LONG OD, INC
Entity Type:Organization
Organization Name:DEREK S LONG OD, INC
Other - Org Name:MAUMELLE EYE CARE
Other - Org Type:Doing Business As
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 1:115 AUDUBON DR STE 8
Practice Address - Street 2:
Practice Address - City:MAUMELLE
Practice Address - State:AR
Practice Address - Zip Code:72113-7409
Practice Address - Country:US
Practice Address - Phone:501-803-3937
Practice Address - Fax:501-803-3962
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-01
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
AR178313722Medicaid
AR5G231Medicare PIN