Provider Demographics
NPI:1578700217
Name:WILSON, JOHN R (BOCPO)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:R
Last Name:WILSON
Suffix:
Gender:M
Credentials:BOCPO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1904 SE WASHINGTON BLVD
Mailing Address - Street 2:
Mailing Address - City:BARTLESVILLE
Mailing Address - State:OK
Mailing Address - Zip Code:74006-6736
Mailing Address - Country:US
Mailing Address - Phone:918-333-6900
Mailing Address - Fax:918-335-6687
Practice Address - Street 1:1904 SE WASHINGTON BLVD
Practice Address - Street 2:
Practice Address - City:BARTLESVILLE
Practice Address - State:OK
Practice Address - Zip Code:74006-6736
Practice Address - Country:US
Practice Address - Phone:918-333-6900
Practice Address - Fax:918-335-6687
Is Sole Proprietor?:No
Enumeration Date:2009-01-16
Last Update Date:2009-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKLPO40222Z00000X, 224P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224P00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersProsthetist
No222Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOrthotist