Provider Demographics
NPI:1558820381
Name:WILSON, BRADEN (MD)
Entity type:Individual
Prefix:DR
First Name:BRADEN
Middle Name:
Last Name:WILSON
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 1:3602 W SOUTHERN HILLS BLVD
Mailing Address - Street 2:
Mailing Address - City:ROGERS
Mailing Address - State:AR
Mailing Address - Zip Code:72758-8013
Mailing Address - Country:US
Mailing Address - Phone:479-631-8900
Mailing Address - Fax:479-899-6698
Practice Address - Street 1:3602 W SOUTHERN HILLS BLVD
Practice Address - Street 2:
Practice Address - City:ROGERS
Practice Address - State:AR
Practice Address - Zip Code:72758-8013
Practice Address - Country:US
Practice Address - Phone:479-631-8900
Practice Address - Fax:479-899-6698
Is Sole Proprietor?:No
Enumeration Date:2019-03-19
Last Update Date:2024-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARE16658207W00000X
TXBP20073168207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR303016001Medicaid