Provider Demographics
NPI:1427168566
Name:WILSON, DAVID JAMES (DO)
Entity type:Individual
Prefix:
First Name:DAVID
Middle Name:JAMES
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 1:27 GARY CT
Mailing Address - Street 2:
Mailing Address - City:LAKE OZARK
Mailing Address - State:MO
Mailing Address - Zip Code:65049-6716
Mailing Address - Country:US
Mailing Address - Phone:573-365-7241
Mailing Address - Fax:918-458-3511
Practice Address - Street 1:100 S BLISS AVE
Practice Address - Street 2:
Practice Address - City:TAHLEQUAH
Practice Address - State:OK
Practice Address - Zip Code:74464-2512
Practice Address - Country:US
Practice Address - Phone:918-458-3100
Practice Address - Fax:918-458-3511
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2011-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA01325208600000X
AZ2003208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100174400AMedicaid
AR150600003Medicaid
AR150600003Medicaid
OK8HZ67YMedicare ID - Type UnspecifiedMEDICARE PROVIDER#- WWH