Provider Demographics
NPI:1225388218
Name:DR CONNIE M WILSON PLLC
Entity type:Organization
Organization Name:DR CONNIE M WILSON PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:CONNIE
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:580-504-8084
Mailing Address - Street 1:PO BOX 1987
Mailing Address - Street 2:
Mailing Address - City:ARDMORE
Mailing Address - State:OK
Mailing Address - Zip Code:73402-1987
Mailing Address - Country:US
Mailing Address - Phone:580-504-8084
Mailing Address - Fax:580-657-3335
Practice Address - Street 1:970 NORTHWEST BLVD
Practice Address - Street 2:
Practice Address - City:ARDMORE
Practice Address - State:OK
Practice Address - Zip Code:73401-1534
Practice Address - Country:US
Practice Address - Phone:580-504-8084
Practice Address - Fax:580-657-3335
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-09-17
Last Update Date:2012-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK3394207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty