Provider Demographics
NPI:1972034775
Name:VICK, BRANDON KEITH (MD)
Entity Type:Individual
Prefix:
First Name:BRANDON
Middle Name:KEITH
Last Name:VICK
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 1:612 SOUTH 12TH ST.
Mailing Address - Street 2:FAMILY MEDICINE UAMS-WEST
Mailing Address - City:FORT SMITH
Mailing Address - State:AR
Mailing Address - Zip Code:72901
Mailing Address - Country:US
Mailing Address - Phone:479-785-2431
Mailing Address - Fax:479-785-0732
Practice Address - Street 1:612 SOUTH 12TH ST.
Practice Address - Street 2:FAMILY MEDICINE UAMS-WEST
Practice Address - City:FORT SMITH
Practice Address - State:AR
Practice Address - Zip Code:72901
Practice Address - Country:US
Practice Address - Phone:479-785-2431
Practice Address - Fax:479-785-0732
Is Sole Proprietor?:No
Enumeration Date:2017-03-23
Last Update Date:2019-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
ARE12128207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program