Provider Demographics
NPI:1184882383
Name:CARLYLE, BENJAMIN WAGNER (MD)
Entity type:Individual
Prefix:DR
First Name:BENJAMIN
Middle Name:WAGNER
Last Name:CARLYLE
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:PO BOX 497
Mailing Address - Street 2:
Mailing Address - City:AUGUSTA
Mailing Address - State:AR
Mailing Address - Zip Code:72006-0497
Mailing Address - Country:US
Mailing Address - Phone:870-347-2534
Mailing Address - Fax:
Practice Address - Street 1:3150 E HERITAGE PKWY STE 1
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:AR
Practice Address - Zip Code:72730-5529
Practice Address - Country:US
Practice Address - Phone:479-400-1140
Practice Address - Fax:479-400-1151
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-26
Last Update Date:2025-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARE-7051207Q00000X, 208M00000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR190430001Medicaid