Basic Information
| Provider Information | |||||||||
| NPI: | 1447311824 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WIGDOR | ||||||||
| FirstName: | REUBIN | ||||||||
| MiddleName: | MORRIS | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PHD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 610 E 24TH ST | ||||||||
| Address2: | |||||||||
| City: | TISHOMINGO | ||||||||
| State: | OK | ||||||||
| PostalCode: | 734603245 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5803712343 | ||||||||
| FaxNumber: | 5803712451 | ||||||||
| Practice Location | |||||||||
| Address1: | 120 N FORREST | ||||||||
| Address2: | |||||||||
| City: | STRATFORD | ||||||||
| State: | OK | ||||||||
| PostalCode: | 748724652 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5804367048 | ||||||||
| FaxNumber: | 5807592174 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/12/2006 | ||||||||
| LastUpdateDate: | 07/10/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 07/10/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103T00000X | N | Behavioral Health & Social Service Providers | Psychologist | 103T00000X | 516 | OK | Y | Behavioral Health & Social Service Providers | Psychologist |
ID Information
| ID | Type | State | Issuer | Description | 100632190B | 05 | OK | MEDICAID | 100632190A | 05 | OK | MEDICAID |