Provider Demographics
NPI:1104204015
Name:KULCZYCKI, CARISSA (DO)
Entity Type:Individual
Prefix:
First Name:CARISSA
Middle Name:
Last Name:KULCZYCKI
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5300 N INDEPENDENCE AVE STE 280
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73112-5555
Mailing Address - Country:US
Mailing Address - Phone:405-713-4400
Mailing Address - Fax:405-713-4473
Practice Address - Street 1:3435 NW 56TH ST STE 600
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73112-4442
Practice Address - Country:US
Practice Address - Phone:405-713-4400
Practice Address - Fax:405-713-4473
Is Sole Proprietor?:No
Enumeration Date:2015-05-12
Last Update Date:2019-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK6012207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology