Basic Information
| Provider Information | |||||||||
| NPI: | 1619030996 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WILSON | ||||||||
| FirstName: | GREGORY | ||||||||
| MiddleName: | L | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 9709 E 79TH ST | ||||||||
| Address2: | |||||||||
| City: | TULSA | ||||||||
| State: | OK | ||||||||
| PostalCode: | 741334566 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9189944000 | ||||||||
| FaxNumber: | 9189944090 | ||||||||
| Practice Location | |||||||||
| Address1: | 9709 E 79TH ST | ||||||||
| Address2: | |||||||||
| City: | TULSA | ||||||||
| State: | OK | ||||||||
| PostalCode: | 741334566 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9189944000 | ||||||||
| FaxNumber: | 9189944090 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/18/2006 | ||||||||
| LastUpdateDate: | 08/22/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | 08/22/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 204D00000X | 2754 | OK | N | Allopathic & Osteopathic Physicians | Neuromusculoskeletal Medicine & OMM | 207T00000X | 2754 | OK | Y | Allopathic & Osteopathic Physicians | Neurological Surgery |
ID Information
| ID | Type | State | Issuer | Description | 100125210A | 05 | OK | MEDICAID |