Provider Demographics
NPI:1477564797
Name:WILEY, CLARENCE L SR (MD,MMS,FAAD)
Entity Type:Individual
Prefix:DR
First Name:CLARENCE
Middle Name:L
Last Name:WILEY
Suffix:SR
Gender:M
Credentials:MD,MMS,FAAD
Other - Prefix:DR
Other - First Name:CLARENCE
Other - Middle Name:LAPIERCE
Other - Last Name:WILEY
Other - Suffix:SR
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 2074
Mailing Address - Street 2:
Mailing Address - City:LOWELL
Mailing Address - State:AR
Mailing Address - Zip Code:72745-2074
Mailing Address - Country:US
Mailing Address - Phone:405-278-7911
Mailing Address - Fax:405-278-7925
Practice Address - Street 1:1211 N SHARTEL AVE STE 407
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73103-2425
Practice Address - Country:US
Practice Address - Phone:405-278-7911
Practice Address - Fax:405-278-7925
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-11
Last Update Date:2016-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK12980207N00000X, 207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK243432400OtherMEDICARE
OKB69256Medicare UPIN
OK243432400Medicare ID - Type UnspecifiedPROVIDER
OKB69256Medicare UPIN