Healthcare Provider Details

I. General information

NPI: 1659427391
Provider Name (Legal Business Name): WILLIAM R. GILLOCK M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/26/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7170 S BRADEN AVE # 175
TULSA OK
74136-6329
US

IV. Provider business mailing address

7170 S BRADEN AVE # 175
TULSA OK
74136-6329
US

V. Phone/Fax

Practice location:
  • Phone: 918-481-0994
  • Fax: 918-494-6747
Mailing address:
  • Phone: 918-481-0994
  • Fax: 918-494-6747

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2083X0100X
TaxonomyOccupational Medicine Physician
License Number12966
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: