Provider Demographics
NPI:1407810641
Name:LEWIS, DEREK (MD)
Entity Type:Individual
Prefix:DR
First Name:DEREK
Middle Name:
Last Name:LEWIS
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 1:6209 W 12TH ST
Mailing Address - Street 2:
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72204-1505
Mailing Address - Country:US
Mailing Address - Phone:501-663-5221
Mailing Address - Fax:501-663-6759
Practice Address - Street 1:6209 W 12TH ST
Practice Address - Street 2:
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72204-1505
Practice Address - Country:US
Practice Address - Phone:501-663-5221
Practice Address - Fax:501-663-6759
Is Sole Proprietor?:No
Enumeration Date:2006-04-14
Last Update Date:2010-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARC6631207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR110711001Medicaid
AR110711001Medicaid
AR53139Medicare ID - Type Unspecified