Healthcare Provider Details

I. General information

NPI: 1689777468
Provider Name (Legal Business Name): LEONARD WILKINS O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/06/2006
Last Update Date: 11/14/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

209 WOODLAWN AVE
TAHLEQUAH OK
74464-3317
US

IV. Provider business mailing address

209 WOODLAWN AVE
TAHLEQUAH OK
74464-3317
US

V. Phone/Fax

Practice location:
  • Phone: 918-456-0585
  • Fax: 918-456-6232
Mailing address:
  • Phone: 918-456-0585
  • Fax: 918-456-6232

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152WC0802X
TaxonomyCorneal and Contact Management Optometrist
License Number815
License Number StateOK

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier0676100001
Identifier TypeOTHER
Identifier State
Identifier IssuerDMERC/PIN
# 2
Identifier156833
Identifier TypeOTHER
Identifier State
Identifier IssuerFED NWO
# 3
Identifier100767470A
Identifier TypeMEDICAID
Identifier StateOK
Identifier Issuer
# 4
Identifier5001
Identifier TypeOTHER
Identifier State
Identifier IssuerNEFN DISP
# 5
Identifier900243
Identifier TypeOTHER
Identifier StateOK
Identifier IssuerOK. NWO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: