Provider Demographics
NPI:1184620049
Name:LILES, C. WALLACE JR (OD)
Entity type:Individual
Prefix:
First Name:C.
Middle Name:WALLACE
Last Name:LILES
Suffix:JR
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:703J HIGHWAY 71 N
Mailing Address - Street 2:
Mailing Address - City:MENA
Mailing Address - State:AR
Mailing Address - Zip Code:71953-4395
Mailing Address - Country:US
Mailing Address - Phone:479-394-4215
Mailing Address - Fax:479-394-3455
Practice Address - Street 1:208 MORROW ST S
Practice Address - Street 2:
Practice Address - City:MENA
Practice Address - State:AR
Practice Address - Zip Code:71953-2510
Practice Address - Country:US
Practice Address - Phone:479-394-4215
Practice Address - Fax:479-394-3455
Is Sole Proprietor?:No
Enumeration Date:2005-06-24
Last Update Date:2019-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARAR2331152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR103836722Medicaid
AR103836722Medicaid
AR0243260001Medicare NSC
AR48113Medicare PIN