Healthcare Provider Details

I. General information

NPI: 1417082710
Provider Name (Legal Business Name): ROGER LEW HIATT JR. MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/23/2007
Last Update Date: 12/23/2019
Certification Date: 12/23/2019
Deactivation Date:
Reactivation Date:

III. Provider practice location address

600 N 7TH ST
WEST MEMPHIS AR
72301-3235
US

IV. Provider business mailing address

10047 BUSHROD CV
COLLIERVILLE TN
38017-9188
US

V. Phone/Fax

Practice location:
  • Phone: 870-394-7100
  • Fax: 870-394-7111
Mailing address:
  • Phone: 801-200-5050
  • Fax: 870-394-7111

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License NumberN-8381
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: