Provider Demographics
NPI:1083944144
Name:SANDERS, WILKIW
Entity Type:Individual
Prefix:
First Name:WILKIW
Middle Name:
Last Name:SANDERS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1168 N DOUGLAS BLVD APT 118
Mailing Address - Street 2:
Mailing Address - City:MIDWEST CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73130-1325
Mailing Address - Country:US
Mailing Address - Phone:405-537-9252
Mailing Address - Fax:
Practice Address - Street 1:1168 N DOUGLAS BLVD APT 118
Practice Address - Street 2:
Practice Address - City:MIDWEST CITY
Practice Address - State:OK
Practice Address - Zip Code:73130-1325
Practice Address - Country:US
Practice Address - Phone:405-537-9252
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-01-12
Last Update Date:2010-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OKH081993789Medicaid