Healthcare Provider Details

I. General information

NPI: 1417453234
Provider Name (Legal Business Name): DERRICK ALAN HENRY MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/02/2018
Last Update Date: 07/02/2024
Certification Date: 07/02/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

800 FAIR PARK BLVD
LITTLE ROCK AR
72204-1720
US

IV. Provider business mailing address

800 FAIR PARK BLVD
LITTLE ROCK AR
72204-1720
US

V. Phone/Fax

Practice location:
  • Phone: 501-404-8007
  • Fax: 501-904-3620
Mailing address:
  • Phone: 501-404-8007
  • Fax: 501-904-3620

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207XX0004X
TaxonomyOrthopaedic Foot and Ankle Surgery Physician
License NumberE-16463
License Number StateAR
# 2
Primary TaxonomyN
Taxonomy Code207XX0004X
TaxonomyOrthopaedic Foot and Ankle Surgery Physician
License Number31406
License Number StateMS
# 3
Primary TaxonomyN
Taxonomy Code207XX0004X
TaxonomyOrthopaedic Foot and Ankle Surgery Physician
License Number67994
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: