Healthcare Provider Details

I. General information

NPI: 1447311824
Provider Name (Legal Business Name): REUBIN MORRIS WIGDOR PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/12/2006
Last Update Date: 07/10/2020
Certification Date: 07/10/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

120 N FORREST
STRATFORD OK
74872-4652
US

IV. Provider business mailing address

610 E 24TH ST
TISHOMINGO OK
73460-3245
US

V. Phone/Fax

Practice location:
  • Phone: 580-436-7048
  • Fax: 580-759-2174
Mailing address:
  • Phone: 580-371-2343
  • Fax: 580-371-2451

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number516
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: