Basic Information
| Provider Information | |||||||||
| NPI: | 1063587269 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | DERLIS MARTINO MD PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 9601 LILE DR | ||||||||
| Address2: | SUITE 650 | ||||||||
| City: | LITTLE ROCK | ||||||||
| State: | AR | ||||||||
| PostalCode: | 722056321 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5012232860 | ||||||||
| FaxNumber: | 5012232258 | ||||||||
| Practice Location | |||||||||
| Address1: | 9601 LILE DR | ||||||||
| Address2: | SUITE 650 | ||||||||
| City: | LITTLE ROCK | ||||||||
| State: | AR | ||||||||
| PostalCode: | 722056321 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5012232860 | ||||||||
| FaxNumber: | 5012232258 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/22/2006 | ||||||||
| LastUpdateDate: | 10/09/2007 | ||||||||
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| AuthorizedOfficialLastName: | MARTINO | ||||||||
| AuthorizedOfficialFirstName: | DERLIS | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 5012232860 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208G00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Thoracic Surgery (Cardiothoracic Vascular Surgery) |
No ID Information.