Basic Information
| Provider Information | |||||||||
| NPI: | 1710101977 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WILKES | ||||||||
| FirstName: | BYRON | ||||||||
| MiddleName: | N | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 3805 WEST 28TH | ||||||||
| Address2: | |||||||||
| City: | PINE BLUFF | ||||||||
| State: | AR | ||||||||
| PostalCode: | 71603 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8705364100 | ||||||||
| FaxNumber: | 8705369020 | ||||||||
| Practice Location | |||||||||
| Address1: | 3805 WEST 28TH | ||||||||
| Address2: | |||||||||
| City: | PINE BLUFF | ||||||||
| State: | AR | ||||||||
| PostalCode: | 71603 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8705364100 | ||||||||
| FaxNumber: | 8705369020 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/12/2007 | ||||||||
| LastUpdateDate: | 11/12/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | 11/12/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 44011 | KY | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207W00000X | 48307 | TN | N | Allopathic & Osteopathic Physicians | Ophthalmology | 207W00000X | 44011 | KY | N | Allopathic & Osteopathic Physicians | Ophthalmology | 207W00000X | E7828 | AR | Y | Allopathic & Osteopathic Physicians | Ophthalmology |
ID Information
| ID | Type | State | Issuer | Description | 201012220 | 05 | IN | MEDICAID | 124105 | 01 | KY | SIHO - NICC | OTHER | 193042001 | 05 | AR | MEDICAID | 000000704725 | 01 | KY | ANTHEM - NICC | OTHER | 1529033 | 05 | TN | MEDICAID | 7100137070 | 05 | KY | MEDICAID |