Provider Demographics
NPI:1356317507
Name:DEROSSITT, JAMES PRENTICE (MD)
Entity type:Individual
Prefix:DR
First Name:JAMES
Middle Name:PRENTICE
Last Name:DEROSSITT
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:PO BOX 1687
Mailing Address - Street 2:
Mailing Address - City:WEST MEMPHIS
Mailing Address - State:AR
Mailing Address - Zip Code:72303-1687
Mailing Address - Country:US
Mailing Address - Phone:870-732-5448
Mailing Address - Fax:870-732-1734
Practice Address - Street 1:210 S RHODES
Practice Address - Street 2:
Practice Address - City:WEST MEMPHIS
Practice Address - State:AR
Practice Address - Zip Code:72301-1687
Practice Address - Country:US
Practice Address - Phone:870-732-5448
Practice Address - Fax:870-732-1734
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-02-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARC5392207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
ARB59527Medicare UPIN
AR51353Medicare ID - Type Unspecified