Healthcare Provider Details

I. General information

NPI: 1699903062
Provider Name (Legal Business Name): HEATHER WILSON MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/24/2009
Last Update Date: 03/31/2026
Certification Date: 03/31/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1200 CHILDRENS AVE STE 12604
OKLAHOMA CITY OK
73104-4637
US

IV. Provider business mailing address

915 NW 14TH ST
OKLAHOMA CITY OK
73106-6601
US

V. Phone/Fax

Practice location:
  • Phone: 405-271-6372
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number30930
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: