Healthcare Provider Details

I. General information

NPI: 1255335527
Provider Name (Legal Business Name): VICTOR THOMAS WILSON M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/02/2005
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

700 WALL ST
NORMAN OK
73069-6360
US

IV. Provider business mailing address

PO BOX 721678
NORMAN OK
73070-8284
US

V. Phone/Fax

Practice location:
  • Phone: 405-360-7337
  • Fax: 866-259-0044
Mailing address:
  • Phone: 405-360-7337
  • Fax: 866-259-0044

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number17516
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: