Provider Demographics
NPI:1922094184
Name:WILSON, RYAN D (DO)
Entity Type:Individual
Prefix:
First Name:RYAN
Middle Name:D
Last Name:WILSON
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 1:5701 SE 74TH ST
Mailing Address - Street 2:SUITE E
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73135-1106
Mailing Address - Country:US
Mailing Address - Phone:405-600-6869
Mailing Address - Fax:405-600-6978
Practice Address - Street 1:800 24TH AVE
Practice Address - Street 2:
Practice Address - City:NORMAN
Practice Address - State:OK
Practice Address - Zip Code:73069
Practice Address - Country:US
Practice Address - Phone:405-321-7100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-09-23
Last Update Date:2022-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK4123207Q00000X, 207PE0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207PE0004XAllopathic & Osteopathic PhysiciansEmergency MedicineEmergency Medical Services
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200022310AMedicaid
OK245522002Medicare ID - Type Unspecified
H96796Medicare UPIN
OK200022310AMedicaid