Provider Demographics
NPI:1699734368
Name:LONG, DEREK SCOTT (OD)
Entity type:Individual
Prefix:DR
First Name:DEREK
Middle Name:SCOTT
Last Name:LONG
Suffix:
Gender:M
Credentials:OD
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Mailing Address - Street 1:115 AUDUBON DR
Mailing Address - Street 2:SUITE 8
Mailing Address - City:MAUMELLE
Mailing Address - State:AR
Mailing Address - Zip Code:72113-7408
Mailing Address - Country:US
Mailing Address - Phone:501-803-3937
Mailing Address - Fax:501-803-3962
Practice Address - Street 1:115 AUDUBON DR
Practice Address - Street 2:SUITE 8
Practice Address - City:MAUMELLE
Practice Address - State:AR
Practice Address - Zip Code:72113-7408
Practice Address - Country:US
Practice Address - Phone:501-803-3937
Practice Address - Fax:501-803-3962
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-21
Last Update Date:2010-05-24
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
ARAR2547152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR154833722Medicaid
AR49887Medicare PIN
ARV00879Medicare UPIN
AR154833722Medicaid