Healthcare Provider Details

I. General information

NPI: 1881867398
Provider Name (Legal Business Name): BRANDON CLARK HICKS M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/04/2008
Last Update Date: 07/08/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

620 N MAIN ST
HARRISON AR
72601-2911
US

IV. Provider business mailing address

219 LANDON LN
HARRISON AR
72601-1814
US

V. Phone/Fax

Practice location:
  • Phone: 501-686-8000
  • Fax:
Mailing address:
  • Phone: 501-240-4096
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberE-8682
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: