Provider Demographics
NPI:1538498472
Name:NILES, BRIAN S (MD)
Entity Type:Individual
Prefix:DR
First Name:BRIAN
Middle Name:S
Last Name:NILES
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 1:609 FULTON ST
Mailing Address - Street 2:
Mailing Address - City:BLYTHEVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72315-1922
Mailing Address - Country:US
Mailing Address - Phone:870-763-0855
Mailing Address - Fax:870-763-0858
Practice Address - Street 1:609 FULTON ST
Practice Address - Street 2:
Practice Address - City:BLYTHEVILLE
Practice Address - State:AR
Practice Address - Zip Code:72315-1922
Practice Address - Country:US
Practice Address - Phone:870-763-0855
Practice Address - Fax:870-763-0858
Is Sole Proprietor?:No
Enumeration Date:2009-12-23
Last Update Date:2013-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2009034738208800000X
ARE-7820208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology