Basic Information
| Provider Information | |||||||||
| NPI: | 1215910179 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WULLER | ||||||||
| FirstName: | THOMAS | ||||||||
| MiddleName: | G. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 720006 | ||||||||
| Address2: | |||||||||
| City: | NORMAN | ||||||||
| State: | OK | ||||||||
| PostalCode: | 730704006 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4057070900 | ||||||||
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| Practice Location | |||||||||
| Address1: | 511 S WINDSOR DR | ||||||||
| Address2: | |||||||||
| City: | STILLWATER | ||||||||
| State: | OK | ||||||||
| PostalCode: | 74074 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4057070900 | ||||||||
| FaxNumber: | 4057073363 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/23/2005 | ||||||||
| LastUpdateDate: | 07/26/2016 | ||||||||
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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 | 207X00000X | 20206 | OK | Y | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |
ID Information
| ID | Type | State | Issuer | Description | 100057720A | 05 | OK | MEDICAID |