Provider Demographics
NPI:1568502938
Name:BRYANT, DEREK M (MD)
Entity Type:Individual
Prefix:
First Name:DEREK
Middle Name:M
Last Name:BRYANT
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 1:408 OFFICE PARK DR STE 3
Mailing Address - Street 2:
Mailing Address - City:BRYANT
Mailing Address - State:AR
Mailing Address - Zip Code:72022-7536
Mailing Address - Country:US
Mailing Address - Phone:501-847-2835
Mailing Address - Fax:501-847-6809
Practice Address - Street 1:4300 W 7TH ST
Practice Address - Street 2:
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72205-5446
Practice Address - Country:US
Practice Address - Phone:501-257-5742
Practice Address - Fax:501-257-5744
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-07
Last Update Date:2019-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARE-2234207Q00000X, 207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ARG78491Medicare UPIN
AR5C709Medicare ID - Type UnspecifiedMEDICARE CLINIC NUMBER