Provider Demographics
NPI:1760401764
Name:DEROSIER, WESLEY J (OD)
Entity Type:Individual
Prefix:DR
First Name:WESLEY
Middle Name:J
Last Name:DEROSIER
Suffix:
Gender:M
Credentials:OD
Other - Prefix:DR
Other - First Name:WES
Other - Middle Name:
Other - Last Name:DEROSIER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:OD
Mailing Address - Street 1:1001 N GRAND AVE
Mailing Address - Street 2:
Mailing Address - City:TAHLEQUAH
Mailing Address - State:OK
Mailing Address - Zip Code:74464-7017
Mailing Address - Country:US
Mailing Address - Phone:918-456-5511
Mailing Address - Fax:
Practice Address - Street 1:5350 E 31ST ST STE 302
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74135-5008
Practice Address - Country:US
Practice Address - Phone:918-933-4085
Practice Address - Fax:918-779-7794
Is Sole Proprietor?:No
Enumeration Date:2006-07-19
Last Update Date:2019-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK2185152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100769300AMedicaid
OK100769300AMedicaid
OK248235412Medicare PIN