Provider Demographics
NPI:1912910340
Name:DAVIS, WILEY G (MD)
Entity Type:Individual
Prefix:DR
First Name:WILEY
Middle Name:G
Last Name:DAVIS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5002 SW LEE BOULEVARD
Mailing Address - Street 2:
Mailing Address - City:LAWTON
Mailing Address - State:OK
Mailing Address - Zip Code:73505-8320
Mailing Address - Country:US
Mailing Address - Phone:580-531-4512
Mailing Address - Fax:580-531-4519
Practice Address - Street 1:5002 SW LEE BOULEVARD
Practice Address - Street 2:
Practice Address - City:LAWTON
Practice Address - State:OK
Practice Address - Zip Code:73505-8320
Practice Address - Country:US
Practice Address - Phone:580-531-4512
Practice Address - Fax:580-531-4519
Is Sole Proprietor?:No
Enumeration Date:2006-08-15
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK123202084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK15560OtherBNDD
OK15560OtherOBN
AD8776099OtherU.S. DEPT OF JUSTICE
AD8776099OtherU.S. DEPT OF JUSTICE
OK15560OtherBNDD
OK243435306Medicare PIN
AD8776099OtherDEA FEDERAL