Provider Demographics
NPI:1710101977
Name:WILKES, BYRON N (MD)
Entity Type:Individual
Prefix:DR
First Name:BYRON
Middle Name:N
Last Name:WILKES
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 1:3805 WEST 28TH
Mailing Address - Street 2:
Mailing Address - City:PINE BLUFF
Mailing Address - State:AR
Mailing Address - Zip Code:71603
Mailing Address - Country:US
Mailing Address - Phone:870-536-4100
Mailing Address - Fax:870-536-9020
Practice Address - Street 1:3805 WEST 28TH
Practice Address - Street 2:
Practice Address - City:PINE BLUFF
Practice Address - State:AR
Practice Address - Zip Code:71603
Practice Address - Country:US
Practice Address - Phone:870-536-4100
Practice Address - Fax:870-536-9020
Is Sole Proprietor?:No
Enumeration Date:2007-04-12
Last Update Date:2020-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY44011207R00000X, 207W00000X
TN48307207W00000X
ARE7828207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201012220Medicaid
KY124105OtherSIHO - NICC
AR193042001Medicaid
KY000000704725OtherANTHEM - NICC
TN1529033Medicaid
KY7100137070Medicaid
TN1529033Medicaid
KY124105OtherSIHO - NICC
KY000000704725OtherANTHEM - NICC
TN103I183634Medicare PIN