Provider Demographics
NPI:1710147962
Name:WILSON, DAVID STANTON (MD)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:STANTON
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 1:115 LONE OAK CIR
Mailing Address - Street 2:
Mailing Address - City:FORT GIBSON
Mailing Address - State:OK
Mailing Address - Zip Code:74434-5005
Mailing Address - Country:US
Mailing Address - Phone:918-203-2222
Mailing Address - Fax:918-203-2223
Practice Address - Street 1:115 LONE OAK CIR
Practice Address - Street 2:
Practice Address - City:FORT GIBSON
Practice Address - State:OK
Practice Address - Zip Code:74434-5005
Practice Address - Country:US
Practice Address - Phone:918-203-2222
Practice Address - Fax:918-203-2223
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-11
Last Update Date:2014-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK15352208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery