Provider Demographics
NPI:1760829220
Name:WAGONER, DERRICK DURELL (DO)
Entity Type:Individual
Prefix:DR
First Name:DERRICK
Middle Name:DURELL
Last Name:WAGONER
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 1:321 SHAPPEE ST
Mailing Address - Street 2:
Mailing Address - City:HORSEHEADS
Mailing Address - State:NY
Mailing Address - Zip Code:14845-1918
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1800 RENAISSANCE BLVD STE 110
Practice Address - Street 2:
Practice Address - City:EDMOND
Practice Address - State:OK
Practice Address - Zip Code:73013
Practice Address - Country:US
Practice Address - Phone:405-601-2325
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-05-23
Last Update Date:2018-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK63242085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200769850AMedicaid