Provider Demographics
NPI:1770540221
Name:WEIDNER, VICKY LYNN (MD)
Entity type:Individual
Prefix:
First Name:VICKY
Middle Name:LYNN
Last Name:WEIDNER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6767 S YALE AVE STE B
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74136-3302
Mailing Address - Country:US
Mailing Address - Phone:918-494-3000
Mailing Address - Fax:918-494-0003
Practice Address - Street 1:6767 S YALE AVE STE B
Practice Address - Street 2:PHYSICIAN SERVICES OF PHYSICAL THERAPY OF TULSA
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74136-3302
Practice Address - Country:US
Practice Address - Phone:918-494-3000
Practice Address - Fax:918-494-0003
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-27
Last Update Date:2022-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM-16685207P00000X
UT12846203-1205207P00000X
MT113030207P00000X
OK15349208D00000X, 207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK930016273OtherRR MEDICARE
OK100135210AMedicaid
OKP00159520OtherRR MEDICARE
OKP00159520OtherRR MEDICARE
OK930016273OtherRR MEDICARE