Healthcare Provider Details

I. General information

NPI: 1073050308
Provider Name (Legal Business Name): DR. DAVID WAKEFIELD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/25/2017
Last Update Date: 01/28/2022
Certification Date: 01/28/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6655 S YALE AVE
TULSA OK
74136-3326
US

IV. Provider business mailing address

PO BOX 707001
TULSA OK
74170-7001
US

V. Phone/Fax

Practice location:
  • Phone: 918-491-3700
  • Fax: 918-481-4063
Mailing address:
  • Phone: 888-247-0125
  • Fax: 918-502-8001

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number268
License Number StateOK
# 2
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number682
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: