Provider Demographics
NPI:1740609486
Name:WILSON, BROCK DUPREE (DO)
Entity Type:Individual
Prefix:
First Name:BROCK
Middle Name:DUPREE
Last Name:WILSON
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 776075
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60677-6075
Mailing Address - Country:US
Mailing Address - Phone:479-785-2229
Mailing Address - Fax:
Practice Address - Street 1:7001 ROGERS AVE STE 403
Practice Address - Street 2:
Practice Address - City:FORT SMITH
Practice Address - State:AR
Practice Address - Zip Code:72903
Practice Address - Country:US
Practice Address - Phone:479-785-2229
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-04-09
Last Update Date:2018-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
ARE-11321207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program