Basic Information
| Provider Information | |||||||||
| NPI: | 1184633521 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DAVIS | ||||||||
| FirstName: | WILSON | ||||||||
| MiddleName: | L | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 610 E 24TH ST | ||||||||
| Address2: | |||||||||
| City: | TISHOMINGO | ||||||||
| State: | OK | ||||||||
| PostalCode: | 734603245 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5803712343 | ||||||||
| FaxNumber: | 5803713614 | ||||||||
| Practice Location | |||||||||
| Address1: | 610 E 24TH ST | ||||||||
| Address2: | |||||||||
| City: | TISHOMINGO | ||||||||
| State: | OK | ||||||||
| PostalCode: | 73460 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5803712343 | ||||||||
| FaxNumber: | 5803713614 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/05/2006 | ||||||||
| LastUpdateDate: | 08/14/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RG0300X | 21526 | IA | N | Allopathic & Osteopathic Physicians | Internal Medicine | Geriatric Medicine | 207R00000X | 34304 | OK | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 18658 | 01 | IA | BCBS OF IOWA | OTHER | 986306 | 01 | IA | STATE LICENSE | OTHER | 20482 | 01 | IA | IOWA HEALTH SOLUTIONS | OTHER | 0186585 | 05 | IA | MEDICAID | 201590007 | 01 | IA | MO MEDICAID NUMBER | OTHER | 110042495 | 01 | IA | RR MEDICARE | OTHER | AD2074259 | 01 | IA | DEA | OTHER |