Provider Demographics
NPI:1285636829
Name:WHITTAKER, RUNAKO D (MD)
Entity Type:Individual
Prefix:
First Name:RUNAKO
Middle Name:D
Last Name:WHITTAKER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1334 N LANSING AVE
Mailing Address - Street 2:1334 N. LANSING AVE.
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74106-5907
Mailing Address - Country:US
Mailing Address - Phone:918-587-2171
Mailing Address - Fax:918-295-6155
Practice Address - Street 1:1334 N LANSING AVE
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74106-5907
Practice Address - Country:US
Practice Address - Phone:918-587-2171
Practice Address - Fax:918-295-6155
Is Sole Proprietor?:No
Enumeration Date:2005-08-12
Last Update Date:2008-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK21966208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100768880IMedicaid
OK100209060BMedicaid
OK100209060BMedicaid