Basic Information
| Provider Information | |||||||||
| NPI: | 1235176629 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GAUTHIER | ||||||||
| FirstName: | WILFRED | ||||||||
| MiddleName: | S | ||||||||
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| Credential: | MD, FACS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4401 W MEMORIAL RD | ||||||||
| Address2: | SUITE 140 | ||||||||
| City: | OKLAHOMA CITY | ||||||||
| State: | OK | ||||||||
| PostalCode: | 731341785 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4057523162 | ||||||||
| FaxNumber: | 4059365211 | ||||||||
| Practice Location | |||||||||
| Address1: | 921 14TH AVE NW | ||||||||
| Address2: | |||||||||
| City: | ARDMORE | ||||||||
| State: | OK | ||||||||
| PostalCode: | 734011837 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5802235311 | ||||||||
| FaxNumber: | 5802238227 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/02/2006 | ||||||||
| LastUpdateDate: | 05/20/2014 | ||||||||
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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 | 208600000X | 8543 | OK | Y | Allopathic & Osteopathic Physicians | Surgery |
ID Information
| ID | Type | State | Issuer | Description | 100049760A | 05 | OK | MEDICAID |