Individual
DR. DERRICK DURELL WAGONER
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
D.O.
Contact information
Practice address
1800 RENAISSANCE BLVD STE 110, EDMOND, OK 73013
(405) 601-2325
Mailing address
321 SHAPPEE ST, HORSEHEADS, NY 14845-1918
Taxonomy
Speciality
Code
Description
License number
State
2085R0202X
Diagnostic Radiology Physician
Primary
6324
OK
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
200769850A
—
OK
Enumeration date
05/23/2013
Last updated
08/29/2025
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