Provider Demographics
NPI:1962510438
Name:OSTEOPATHIC CARDIOVASCULAR SURG INC
Entity Type:Organization
Organization Name:OSTEOPATHIC CARDIOVASCULAR SURG INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SURGEON
Authorized Official - Prefix:
Authorized Official - First Name:LARRY
Authorized Official - Middle Name:
Authorized Official - Last Name:DULLYE
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:918-585-3372
Mailing Address - Street 1:802 S JACKSON #200
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74127-9047
Mailing Address - Country:US
Mailing Address - Phone:918-585-3372
Mailing Address - Fax:918-599-9116
Practice Address - Street 1:802 S JACKSON #200
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74127-9047
Practice Address - Country:US
Practice Address - Phone:918-585-3372
Practice Address - Fax:918-599-9116
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-26
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK1962208G00000X
OK1569208G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)Group - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
D42531 E09827 F36165Medicare UPIN
OKH11245Medicare UPIN
OKTSSCSMedicare ID - Type Unspecified