MEDICARE: DR. GREGORY L WILSON D.O.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	204D00000X	Neuromusculoskeletal Medicine & OMM Physician	2754	OK
2	207T00000X	Neurological Surgery Physician	2754	OK

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1619030996
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. GREGORY L WILSON D.O.

Provider Business Mailing Address
First Line	:	9709 E 79TH ST
Second Line	:
City	:	TULSA
State	:	OK
Zip	:	74133-4566
Country	:	US
Telephone Number	:	918-994-4000
Fax Number	:	918-994-4090

Provider Business Practice Location Address
First Line	:	9709 E 79TH ST
Second Line	:
City	:	TULSA
State	:	OK
Zip	:	74133-4566
Country	:	US
Telephone Number	:	918-994-4000
Fax Number	:	918-994-4090

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/18/2006
Last Update Date	:	08/22/2022

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