Provider Demographics
NPI:1952517732
Name:WILKERSON, TRACY LEE (DO)
Entity Type:Individual
Prefix:
First Name:TRACY
Middle Name:LEE
Last Name:WILKERSON
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:TRACY
Other - Middle Name:LEE
Other - Last Name:WILKERSON-BURTON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DO
Mailing Address - Street 1:101 S PARK LN
Mailing Address - Street 2:
Mailing Address - City:ALTUS
Mailing Address - State:OK
Mailing Address - Zip Code:73521-5731
Mailing Address - Country:US
Mailing Address - Phone:580-379-6140
Mailing Address - Fax:580-379-6149
Practice Address - Street 1:101 S PARK LN
Practice Address - Street 2:
Practice Address - City:ALTUS
Practice Address - State:OK
Practice Address - Zip Code:73521-5731
Practice Address - Country:US
Practice Address - Phone:580-379-6140
Practice Address - Fax:580-379-6149
Is Sole Proprietor?:No
Enumeration Date:2007-05-16
Last Update Date:2018-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK4707207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI5101016863OtherSTATE LICENSE
OK200294320AMedicaid
OKP01083969OtherRAILROAD MEDICARE
OK4707OtherOK
OK200294320AMedicaid