Provider Demographics
NPI:1124864111
Name:BANKS, BRYLEY JAE (OD)
Entity type:Individual
Prefix:DR
First Name:BRYLEY
Middle Name:JAE
Last Name:BANKS
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1021 S WALDRON RD
Mailing Address - Street 2:
Mailing Address - City:FORT SMITH
Mailing Address - State:AR
Mailing Address - Zip Code:72903-2549
Mailing Address - Country:US
Mailing Address - Phone:479-478-8860
Mailing Address - Fax:
Practice Address - Street 1:1021 S WALDRON RD
Practice Address - Street 2:
Practice Address - City:FORT SMITH
Practice Address - State:AR
Practice Address - Zip Code:72903-2549
Practice Address - Country:US
Practice Address - Phone:417-629-0505
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-07-08
Last Update Date:2024-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2024020536152W00000X
AR2882152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist