=====================================================
General NPI Number Information
=====================================================
NPI Number | 1649258369
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JAMES DULL RUTTER IV MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/03/2006
-----------------------------------------------------
Last Update Date | 04/05/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 900 E 13TH ST SUITE 101
-----------------------------------------------------
City | GROVE
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 74344-2976
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 918-786-9900
-----------------------------------------------------
Fax | 918-786-9904
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5300 N INDEPENDENCE AVE 280
-----------------------------------------------------
City | OKLAHOMA CITY
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 73112-5556
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 918-786-9900
-----------------------------------------------------
Fax | 918-786-9904
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207R00000X
-----------------------------------------------------
Taxonomy Name | Internal Medicine Physician
-----------------------------------------------------
License Number | 21574
-----------------------------------------------------
License Number State | OK
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 208000000X
-----------------------------------------------------
Taxonomy Name | Pediatrics Physician
-----------------------------------------------------
License Number | 21574
-----------------------------------------------------
License Number State | OK
-----------------------------------------------------