Provider Demographics
NPI:1699828186
Name:WEILERT, BRENT R (MD)
Entity Type:Individual
Prefix:
First Name:BRENT
Middle Name:R
Last Name:WEILERT
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12 E APPLEBY RD
Mailing Address - Street 2:CLINIC ADMINISTRATION
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72703-3901
Mailing Address - Country:US
Mailing Address - Phone:479-463-1704
Mailing Address - Fax:479-463-7864
Practice Address - Street 1:3336 NORTH FUTRALL DRIVE
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:AR
Practice Address - Zip Code:72703
Practice Address - Country:US
Practice Address - Phone:479-463-3000
Practice Address - Fax:479-463-3050
Is Sole Proprietor?:No
Enumeration Date:2007-01-19
Last Update Date:2010-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARE-5218207LP2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR5N836OtherBCBS
AR164614001Medicaid
ARP00405693OtherRR MCR
AR5N836OtherBCBS
AR164614001Medicaid