Provider Demographics
NPI:1639575160
Name:INVICTUS HEALTHCARE SYSTEM, PLLC
Entity Type:Organization
Organization Name:INVICTUS HEALTHCARE SYSTEM, PLLC
Other - Org Name:INVICTUS HEALTHCARE SYSTEM
Other - Org Type:Doing Business As
Authorized Official - Title/Position:BUSINESS OWNER
Authorized Official - Prefix:
Authorized Official - First Name:GREGORY
Authorized Official - Middle Name:L
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:918-994-4000
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
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-11-11
Last Update Date:2022-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK25510207LP2900X
OK2574207T00000X
OK4272207XX0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological SurgeryGroup - Multi-Specialty
No207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain MedicineGroup - Multi-Specialty
No207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200563910AMedicaid
OK200563910AMedicaid