Provider Demographics
NPI:1649233321
Name:MUCKALA, KENNETH A (MD)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:A
Last Name:MUCKALA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:7912 E 31ST CT
Mailing Address - Street 2:SUITE 100
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74145-1315
Mailing Address - Country:US
Mailing Address - Phone:918-743-8200
Mailing Address - Fax:918-743-8609
Practice Address - Street 1:7912 E 31ST CT
Practice Address - Street 2:SUITE 100
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74145-1315
Practice Address - Country:US
Practice Address - Phone:918-743-8200
Practice Address - Fax:918-743-8200
Is Sole Proprietor?:No
Enumeration Date:2006-04-11
Last Update Date:2010-01-11
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
OK16314207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100172890BMedicaid
OK100172890BMedicaid
OKC95269Medicare UPIN