Provider Demographics
NPI:1083921191
Name:WILSON, BRANDON MARAY (DO)
Entity Type:Individual
Prefix:DR
First Name:BRANDON
Middle Name:MARAY
Last Name:WILSON
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1120 S UTICA AVE
Mailing Address - Street 2:SUITE G100
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74104-4012
Mailing Address - Country:US
Mailing Address - Phone:918-392-0175
Mailing Address - Fax:918-392-0176
Practice Address - Street 1:1120 S UTICA AVE
Practice Address - Street 2:SUITE G100
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74104-4012
Practice Address - Country:US
Practice Address - Phone:918-392-0175
Practice Address - Fax:918-392-0176
Is Sole Proprietor?:No
Enumeration Date:2010-09-10
Last Update Date:2014-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK4976207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200304180AMedicaid
OK200304180AMedicaid