Provider Demographics
NPI:1063491801
Name:WILSON, MICHAEL W (DO)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:W
Last Name:WILSON
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2777 NW 222ND ST
Mailing Address - Street 2:
Mailing Address - City:EDMOND
Mailing Address - State:OK
Mailing Address - Zip Code:73025-9087
Mailing Address - Country:US
Mailing Address - Phone:405-659-7114
Mailing Address - Fax:
Practice Address - Street 1:11601 S WESTERN AVE
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73170-5823
Practice Address - Country:US
Practice Address - Phone:405-691-5208
Practice Address - Fax:405-378-0556
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-11
Last Update Date:2016-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK3890207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK241416713Medicare ID - Type Unspecified
OKH80634Medicare UPIN