Provider Demographics
NPI:1881662013
Name:WENGER, JILL L (MD)
Entity Type:Individual
Prefix:DR
First Name:JILL
Middle Name:L
Last Name:WENGER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1919 S WHEELING AVE
Mailing Address - Street 2:404
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74104-5638
Mailing Address - Country:US
Mailing Address - Phone:918-748-7520
Mailing Address - Fax:918-293-3113
Practice Address - Street 1:1919 S WHEELING AVE
Practice Address - Street 2:404
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74104-5638
Practice Address - Country:US
Practice Address - Phone:918-748-7520
Practice Address - Fax:918-293-3113
Is Sole Proprietor?:No
Enumeration Date:2006-03-14
Last Update Date:2007-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK20402207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OKG57456Medicare UPIN