Provider Demographics
NPI:1417453234
Name:HENRY, DERRICK ALAN (MD)
Entity type:Individual
Prefix:
First Name:DERRICK
Middle Name:ALAN
Last Name:HENRY
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 1:800 FAIR PARK BLVD
Mailing Address - Street 2:
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72204-1720
Mailing Address - Country:US
Mailing Address - Phone:501-404-8007
Mailing Address - Fax:501-904-3620
Practice Address - Street 1:800 FAIR PARK BLVD
Practice Address - Street 2:
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72204-1720
Practice Address - Country:US
Practice Address - Phone:501-404-8007
Practice Address - Fax:501-904-3620
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-02
Last Update Date:2024-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARE-16463207XX0004X
MS31406207XX0004X
TN67994207XX0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XX0004XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryFoot and Ankle Surgery