MEDICARE: DR. CLARENCE L WILEY SR. M.D.,M.M.S.,F.A.A.D

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207N00000X	Dermatology Physician	12980	OK

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	243432400	OTHER	OK	MEDICARE

General Provider Information

NPI Number	:	1477564797
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. CLARENCE L WILEY SR. M.D.,M.M.S.,F.A.A.D

Provider Business Mailing Address
First Line	:	PO BOX 2074
Second Line	:
City	:	LOWELL
State	:	AR
Zip	:	72745-2074
Country	:	US
Telephone Number	:	405-278-7911
Fax Number	:	405-278-7925

Provider Business Practice Location Address
First Line	:	1211 N SHARTEL AVE STE 407
Second Line	:
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73103-2425
Country	:	US
Telephone Number	:	405-278-7911
Fax Number	:	405-278-7925

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/11/2006
Last Update Date	:	08/04/2016

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