Provider Demographics
NPI:1710428958
Name:WALKUP, STORMY RAY (DO)
Entity Type:Individual
Prefix:DR
First Name:STORMY
Middle Name:RAY
Last Name:WALKUP
Suffix:
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 1:1302 S LYNN LN
Mailing Address - Street 2:
Mailing Address - City:IDABEL
Mailing Address - State:OK
Mailing Address - Zip Code:74745-6860
Mailing Address - Country:US
Mailing Address - Phone:805-286-3993
Mailing Address - Fax:580-286-3967
Practice Address - Street 1:1302 S LYNN LN
Practice Address - Street 2:
Practice Address - City:IDABEL
Practice Address - State:OK
Practice Address - Zip Code:74745-6860
Practice Address - Country:US
Practice Address - Phone:580-286-3993
Practice Address - Fax:580-286-3967
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-20
Last Update Date:2021-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK6273207Q00000X, 207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200730970AMedicaid