Provider Demographics
NPI:1184633521
Name:DAVIS, WILSON L (MD)
Entity Type:Individual
Prefix:
First Name:WILSON
Middle Name:L
Last Name:DAVIS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:610 E 24TH ST
Mailing Address - Street 2:
Mailing Address - City:TISHOMINGO
Mailing Address - State:OK
Mailing Address - Zip Code:73460-3245
Mailing Address - Country:US
Mailing Address - Phone:580-371-2343
Mailing Address - Fax:580-371-3614
Practice Address - Street 1:610 E 24TH ST
Practice Address - Street 2:
Practice Address - City:TISHOMINGO
Practice Address - State:OK
Practice Address - Zip Code:73460
Practice Address - Country:US
Practice Address - Phone:580-371-2343
Practice Address - Fax:580-371-3614
Is Sole Proprietor?:No
Enumeration Date:2006-08-05
Last Update Date:2022-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK34304207R00000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA18658OtherBCBS OF IOWA
IA986306OtherSTATE LICENSE
IA20482OtherIOWA HEALTH SOLUTIONS
IA0186585Medicaid
IA201590007OtherMO MEDICAID NUMBER
IA110042495OtherRR MEDICARE
IAAD2074259OtherDEA
IA18658OtherBCBS OF IOWA