Provider Demographics
NPI:1437443173
Name:ENZS, DEREK S (RVT)
Entity Type:Individual
Prefix:
First Name:DEREK
Middle Name:S
Last Name:ENZS
Suffix:
Gender:M
Credentials:RVT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:716 W EMERSON ST
Mailing Address - Street 2:
Mailing Address - City:PARAGOULD
Mailing Address - State:AR
Mailing Address - Zip Code:72450-5924
Mailing Address - Country:US
Mailing Address - Phone:870-476-7101
Mailing Address - Fax:
Practice Address - Street 1:716 W EMERSON ST
Practice Address - Street 2:
Practice Address - City:PARAGOULD
Practice Address - State:AR
Practice Address - Zip Code:72450-5924
Practice Address - Country:US
Practice Address - Phone:870-476-7101
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-05-29
Last Update Date:2011-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS313069247100000X
KS960742471S1302X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2471S1302XTechnologists, Technicians & Other Technical Service ProvidersRadiologic TechnologistSonography
No247100000XTechnologists, Technicians & Other Technical Service ProvidersRadiologic Technologist