Provider Demographics
NPI:1255577532
Name:DEREK S LONG OD INC
Entity type:Organization
Organization Name:DEREK S LONG OD INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DOCTOR
Authorized Official - Prefix:
Authorized Official - First Name:DEREK
Authorized Official - Middle Name:S
Authorized Official - Last Name:LONG
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:501-803-3937
Mailing Address - Street 1:406 W PERSHING BLVD
Mailing Address - Street 2:
Mailing Address - City:NORTH LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72114-2146
Mailing Address - Country:US
Mailing Address - Phone:501-753-3145
Mailing Address - Fax:501-753-1806
Practice Address - Street 1:406 W PERSHING BLVD
Practice Address - Street 2:
Practice Address - City:NORTH LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72114-2146
Practice Address - Country:US
Practice Address - Phone:501-753-3145
Practice Address - Fax:501-753-1806
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-12-17
Last Update Date:2011-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR2547152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR1487812392Medicaid
AR5G233Medicare PIN
AR6362850001Medicare NSC