Provider Demographics
NPI:1447311824
Name:WIGDOR, REUBIN MORRIS (PHD)
Entity type:Individual
Prefix:DR
First Name:REUBIN
Middle Name:MORRIS
Last Name:WIGDOR
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:610 E 24TH ST
Mailing Address - Street 2:
Mailing Address - City:TISHOMINGO
Mailing Address - State:OK
Mailing Address - Zip Code:73460-3245
Mailing Address - Country:US
Mailing Address - Phone:580-371-2343
Mailing Address - Fax:580-371-2451
Practice Address - Street 1:120 N FORREST
Practice Address - Street 2:
Practice Address - City:STRATFORD
Practice Address - State:OK
Practice Address - Zip Code:74872-4652
Practice Address - Country:US
Practice Address - Phone:580-436-7048
Practice Address - Fax:580-759-2174
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-12
Last Update Date:2020-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103T00000X
OK516103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100632190BMedicaid
OK100632190AMedicaid