Provider Demographics
NPI:1518933290
Name:WILSON, JODY M (MD)
Entity Type:Individual
Prefix:
First Name:JODY
Middle Name:M
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 1:1401 E VAN BUREN AVE
Mailing Address - Street 2:
Mailing Address - City:MCALESTER
Mailing Address - State:OK
Mailing Address - Zip Code:74501-4245
Mailing Address - Country:US
Mailing Address - Phone:918-421-8410
Mailing Address - Fax:918-421-8772
Practice Address - Street 1:1401 E VAN BUREN AVE
Practice Address - Street 2:
Practice Address - City:MCALESTER
Practice Address - State:OK
Practice Address - Zip Code:74501-4245
Practice Address - Country:US
Practice Address - Phone:918-421-8410
Practice Address - Fax:918-421-8772
Is Sole Proprietor?:No
Enumeration Date:2006-02-23
Last Update Date:2018-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK25350208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX037735003Medicaid
TX8950B6Medicare ID - Type Unspecified
TX037735003Medicaid