Healthcare Provider Details

I. General information

NPI: 1427168566
Provider Name (Legal Business Name): DAVID JAMES WILSON D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/30/2006
Last Update Date: 01/25/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 S BLISS AVE
TAHLEQUAH OK
74464-2512
US

IV. Provider business mailing address

27 GARY CT
LAKE OZARK MO
65049-6716
US

V. Phone/Fax

Practice location:
  • Phone: 918-458-3100
  • Fax: 918-458-3511
Mailing address:
  • Phone: 573-365-7241
  • Fax: 918-458-3511

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number01325
License Number StateIA
# 2
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number2003
License Number StateAZ

VII. Legacy identifiers

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

# 1
Identifier100174400A
Identifier TypeMEDICAID
Identifier StateOK
Identifier Issuer
# 2
Identifier150600003
Identifier TypeMEDICAID
Identifier StateAR
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: