Healthcare Provider Details

I. General information

NPI: 1619030996
Provider Name (Legal Business Name): GREGORY L WILSON D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/18/2006
Last Update Date: 08/22/2022
Certification Date: 08/22/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9709 E 79TH ST
TULSA OK
74133-4566
US

IV. Provider business mailing address

9709 E 79TH ST
TULSA OK
74133-4566
US

V. Phone/Fax

Practice location:
  • Phone: 918-994-4000
  • Fax: 918-994-4090
Mailing address:
  • Phone: 918-994-4000
  • Fax: 918-994-4090

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code204D00000X
TaxonomyNeuromusculoskeletal Medicine & OMM Physician
License Number2754
License Number StateOK
# 2
Primary TaxonomyY
Taxonomy Code207T00000X
TaxonomyNeurological Surgery Physician
License Number2754
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: