Provider Demographics
NPI:1043505456
Name:CONNIE M WILSON DO PC
Entity Type:Organization
Organization Name:CONNIE M WILSON DO PC
Other - Org Name:WILSON LOUGHRIDGE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER / PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:CONNIE
Authorized Official - Middle Name:M
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:580-504-5596
Mailing Address - Street 1:PO BOX 1987
Mailing Address - Street 2:
Mailing Address - City:ARDMORE
Mailing Address - State:OK
Mailing Address - Zip Code:73402-1987
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1005 15TH AVE NW
Practice Address - Street 2:
Practice Address - City:ARDMORE
Practice Address - State:OK
Practice Address - Zip Code:73401-1810
Practice Address - Country:US
Practice Address - Phone:580-226-1010
Practice Address - Fax:580-226-1011
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-06-14
Last Update Date:2011-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK3394207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OKOKAAA1456Medicare PIN