Provider Demographics
NPI:1962463810
Name:WILSON, GEORGE KRISTOPHER (DC)
Entity Type:Individual
Prefix:DR
First Name:GEORGE
Middle Name:KRISTOPHER
Last Name:WILSON
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:788 N SANTA FE AVE
Mailing Address - Street 2:SUITE 110
Mailing Address - City:EDMOND
Mailing Address - State:OK
Mailing Address - Zip Code:73003-4300
Mailing Address - Country:US
Mailing Address - Phone:405-285-0300
Mailing Address - Fax:405-285-0455
Practice Address - Street 1:788 N SANTA FE AVE
Practice Address - Street 2:SUITE 110
Practice Address - City:EDMOND
Practice Address - State:OK
Practice Address - Zip Code:73003-4300
Practice Address - Country:US
Practice Address - Phone:405-285-0300
Practice Address - Fax:405-285-0455
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-30
Last Update Date:2014-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK3391111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK245602301Medicare PIN