Provider Demographics
NPI:1083718266
Name:HEWITT, DEREK KERN (MD)
Entity Type:Individual
Prefix:
First Name:DEREK
Middle Name:KERN
Last Name:HEWITT
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 7687
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:MO
Mailing Address - Zip Code:65202
Mailing Address - Country:US
Mailing Address - Phone:573-882-2259
Mailing Address - Fax:573-884-8526
Practice Address - Street 1:1125 W IRON SPRINGS RD
Practice Address - Street 2:
Practice Address - City:PRESCOTT
Practice Address - State:AZ
Practice Address - Zip Code:86305-1623
Practice Address - Country:US
Practice Address - Phone:928-778-9190
Practice Address - Fax:928-778-3005
Is Sole Proprietor?:No
Enumeration Date:2006-09-11
Last Update Date:2012-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOT2003013836207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology