Provider Demographics
NPI:1295983237
Name:DE QUEEN PEDIATRICS INC
Entity type:Organization
Organization Name:DE QUEEN PEDIATRICS INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:TERRI
Authorized Official - Middle Name:A
Authorized Official - Last Name:DEVLIN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:870-642-4364
Mailing Address - Street 1:1357 W COLLIN RAYE DR
Mailing Address - Street 2:
Mailing Address - City:DE QUEEN
Mailing Address - State:AR
Mailing Address - Zip Code:71832-2946
Mailing Address - Country:US
Mailing Address - Phone:870-642-4364
Mailing Address - Fax:
Practice Address - Street 1:1357 W COLLIN RAYE DR
Practice Address - Street 2:
Practice Address - City:DE QUEEN
Practice Address - State:AR
Practice Address - Zip Code:71832-2946
Practice Address - Country:US
Practice Address - Phone:870-642-4364
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-09-03
Last Update Date:2014-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARE-2169208D00000X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
No208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR170952002Medicaid