Provider Demographics
NPI:1114283124
Name:EWELL, DEREK ALLEN (DO)
Entity Type:Individual
Prefix:
First Name:DEREK
Middle Name:ALLEN
Last Name:EWELL
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2710 HARNEY ST
Mailing Address - Street 2:STE 100
Mailing Address - City:LARAMIE
Mailing Address - State:WY
Mailing Address - Zip Code:82072-0001
Mailing Address - Country:US
Mailing Address - Phone:806-354-5417
Mailing Address - Fax:806-351-3787
Practice Address - Street 1:1400 S COULTER ST
Practice Address - Street 2:TTUHSC
Practice Address - City:AMARILLO
Practice Address - State:TX
Practice Address - Zip Code:79106-1786
Practice Address - Country:US
Practice Address - Phone:806-354-5417
Practice Address - Fax:806-351-3787
Is Sole Proprietor?:No
Enumeration Date:2012-04-03
Last Update Date:2016-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
WY10577A207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program