Provider Demographics
NPI:1619030996
Name:WILSON, GREGORY L (DO)
Entity Type:Individual
Prefix:DR
First Name:GREGORY
Middle Name:L
Last Name:WILSON
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9709 E 79TH ST
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74133-4566
Mailing Address - Country:US
Mailing Address - Phone:918-994-4000
Mailing Address - Fax:918-994-4090
Practice Address - Street 1:9709 E 79TH ST
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74133-4566
Practice Address - Country:US
Practice Address - Phone:918-994-4000
Practice Address - Fax:918-994-4090
Is Sole Proprietor?:No
Enumeration Date:2006-12-18
Last Update Date:2022-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK2754204D00000X, 207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological Surgery
No204D00000XAllopathic & Osteopathic PhysiciansNeuromusculoskeletal Medicine & OMM
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100125210AMedicaid
OK300522142Medicare ID - Type Unspecified
OK100125210AMedicaid