Provider Demographics
NPI:1932177011
Name:WILLISON, FREDERICK W (MD)
Entity Type:Individual
Prefix:
First Name:FREDERICK
Middle Name:W
Last Name:WILLISON
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 1:1923 S UTICA AVE
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74104-6520
Mailing Address - Country:US
Mailing Address - Phone:918-744-2345
Mailing Address - Fax:
Practice Address - Street 1:1923 S UTICA AVE
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74104-6520
Practice Address - Country:US
Practice Address - Phone:918-744-2345
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA01010526842085R0001X
OK201412085R0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
P00214553OtherRAILROAD MEDICARE
3735116OtherAETNA
146643OtherANTHEM BCBS
2129632OtherMAMSI
8646817OtherCIGNA
248895OtherSOUTHERN HEALTH
3735116OtherAETNA
146643OtherANTHEM BCBS