Healthcare Provider Details

I. General information

NPI: 1174244313
Provider Name (Legal Business Name): MIDTOWN OBGYN
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/07/2022
Last Update Date: 09/07/2022
Certification Date: 09/06/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1705 E 19TH ST STE 701
TULSA OK
74104-5418
US

IV. Provider business mailing address

667 W 79TH ST
TULSA OK
74132-2645
US

V. Phone/Fax

Practice location:
  • Phone: 918-549-0497
  • Fax:
Mailing address:
  • Phone: 918-549-0497
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207VG0400X
TaxonomyGynecology Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207VX0000X
TaxonomyObstetrics Physician
License Number
License Number State

VIII. Authorized Official

Name: BRANDON MARAY WILSON
Title or Position: OBGYN
Credential: DO
Phone: 918-549-0497