Provider Demographics
NPI:1801207493
Name:KUBAT, CARLY ANN DYKSTRA (MD)
Entity Type:Individual
Prefix:
First Name:CARLY
Middle Name:ANN DYKSTRA
Last Name:KUBAT
Suffix:
Gender:F
Credentials:MD
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Other - Credentials:
Mailing Address - Street 1:6600 S YALE AVE STE 1400
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74136-3331
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6151 S YALE AVE
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74136-1907
Practice Address - Country:US
Practice Address - Phone:918-502-6097
Practice Address - Fax:918-502-6046
Is Sole Proprietor?:No
Enumeration Date:2014-05-16
Last Update Date:2020-08-04
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
OK360892080N0001X
OH1313502080N0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080N0001XAllopathic & Osteopathic PhysiciansPediatricsNeonatal-Perinatal Medicine