MEDICARE: JOHN R WILSON BOCPO

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	222Z00000X	Orthotist	LPO40	OK
2	224P00000X	Prosthetist	LPO40	OK

General Provider Information

NPI Number	:	1578700217
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JOHN R WILSON BOCPO

Provider Business Mailing Address
First Line	:	1904 SE WASHINGTON BLVD
Second Line	:
City	:	BARTLESVILLE
State	:	OK
Zip	:	74006-6736
Country	:	US
Telephone Number	:	918-333-6900
Fax Number	:	918-335-6687

Provider Business Practice Location Address
First Line	:	1904 SE WASHINGTON BLVD
Second Line	:
City	:	BARTLESVILLE
State	:	OK
Zip	:	74006-6736
Country	:	US
Telephone Number	:	918-333-6900
Fax Number	:	918-335-6687

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

Provider Enumeration Date	:	01/16/2009
Last Update Date	:	01/16/2009

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