Healthcare Provider Details

I. General information

NPI: 1407786676
Provider Name (Legal Business Name): MR. IRVIN WILLIAM WILSON II
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/20/2026
Last Update Date: 05/20/2026
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2508 E. 71ST ST. # C
TULSA OK
74136
US

IV. Provider business mailing address

2508 E. 71ST ST. # C
TULSA OK
74136
US

V. Phone/Fax

Practice location:
  • Phone: 918-794-6570
  • Fax: 918-340-5189
Mailing address:
  • Phone: 918-794-6570
  • Fax: 918-340-5189

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License Number
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: