Healthcare Provider Details

I. General information

NPI: 1235208042
Provider Name (Legal Business Name): LARRY J DULLYE DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/07/2006
Last Update Date: 07/11/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

802 S JACKSON AVE 200
TULSA OK
74127-9015
US

IV. Provider business mailing address

802 S JACKSON AVE 200
TULSA OK
74127-9015
US

V. Phone/Fax

Practice location:
  • Phone: 918-585-3372
  • Fax: 918-599-9116
Mailing address:
  • Phone: 918-585-3372
  • Fax: 918-599-9116

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208G00000X
TaxonomyThoracic Surgery (Cardiothoracic Vascular Surgery) Physician
License Number1569
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: