Healthcare Provider Details

I. General information

NPI: 1649258369
Provider Name (Legal Business Name): JAMES DULL RUTTER IV MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/03/2006
Last Update Date: 04/05/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

900 E 13TH ST SUITE 101
GROVE OK
74344-2976
US

IV. Provider business mailing address

5300 N INDEPENDENCE AVE 280
OKLAHOMA CITY OK
73112-5556
US

V. Phone/Fax

Practice location:
  • Phone: 918-786-9900
  • Fax: 918-786-9904
Mailing address:
  • Phone: 918-786-9900
  • Fax: 918-786-9904

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number21574
License Number StateOK
# 2
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number21574
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: