Healthcare Provider Details

I. General information

NPI: 1104862978
Provider Name (Legal Business Name): WILLIAM WILSON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/21/2006
Last Update Date: 03/27/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7301 SW 44TH ST STE A
OKLAHOMA CITY OK
73179-4309
US

IV. Provider business mailing address

7301 SW 44TH ST STE A
OKLAHOMA CITY OK
73179-4309
US

V. Phone/Fax

Practice location:
  • Phone: 405-357-3500
  • Fax: 405-357-3519
Mailing address:
  • Phone: 405-357-3500
  • Fax: 405-357-3519

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number17867
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: