Provider Demographics
NPI:1376715664
Name:WILSON, ISAIAH (MD)
Entity Type:Individual
Prefix:DR
First Name:ISAIAH
Middle Name:
Last Name:WILSON
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 1:1120 S UTICA AVE
Mailing Address - Street 2:SUITE 3074
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74104-4012
Mailing Address - Country:US
Mailing Address - Phone:918-579-7100
Mailing Address - Fax:918-579-7110
Practice Address - Street 1:1120 S UTICA AVE
Practice Address - Street 2:SUITE 3074
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74104-4012
Practice Address - Country:US
Practice Address - Phone:918-579-7100
Practice Address - Fax:918-579-7110
Is Sole Proprietor?:No
Enumeration Date:2008-03-27
Last Update Date:2020-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK30211208100000X
MI4301095138208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK349086YLV0Medicare PIN