Provider Demographics
NPI:1659331486
Name:MCCULLOUGH, ROBERT DALE II (DO)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:DALE
Last Name:MCCULLOUGH
Suffix:II
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5803 E 75TH PL
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74136-7255
Mailing Address - Country:US
Mailing Address - Phone:918-481-8725
Mailing Address - Fax:
Practice Address - Street 1:5803 E 75TH PL
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74136-7255
Practice Address - Country:US
Practice Address - Phone:918-481-8725
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-24
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK1290207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OKAM5072448OtherDEA