Provider Demographics
NPI:1093840639
Name:WILCOX, ALLISON RUSSANNE (MD)
Entity Type:Individual
Prefix:DR
First Name:ALLISON
Middle Name:RUSSANNE
Last Name:WILCOX
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1108 S KALANCHOE AVE
Mailing Address - Street 2:
Mailing Address - City:BROKEN ARROW
Mailing Address - State:OK
Mailing Address - Zip Code:74012-0977
Mailing Address - Country:US
Mailing Address - Phone:404-695-3685
Mailing Address - Fax:
Practice Address - Street 1:1108 S KALANCHOE AVE
Practice Address - Street 2:
Practice Address - City:BROKEN ARROW
Practice Address - State:OK
Practice Address - Zip Code:74012-0977
Practice Address - Country:US
Practice Address - Phone:404-695-3685
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-23
Last Update Date:2023-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK27558207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100739880AMedicaid
OK268266YLV0Medicare PIN