Provider Demographics
NPI:1649258369
Name:RUTTER, JAMES DULL IV (MD)
Entity type:Individual
Prefix:
First Name:JAMES
Middle Name:DULL
Last Name:RUTTER
Suffix:IV
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:5300 N INDEPENDENCE AVE
Mailing Address - Street 2:280
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73112-5556
Mailing Address - Country:US
Mailing Address - Phone:918-786-9900
Mailing Address - Fax:918-786-9904
Practice Address - Street 1:900 E 13TH ST
Practice Address - Street 2:SUITE 101
Practice Address - City:GROVE
Practice Address - State:OK
Practice Address - Zip Code:74344-2976
Practice Address - Country:US
Practice Address - Phone:918-786-9900
Practice Address - Fax:918-786-9904
Is Sole Proprietor?:No
Enumeration Date:2006-01-03
Last Update Date:2017-04-05
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
OK21574207R00000X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO209007509Medicaid
OK100103090BMedicaid
OK200505990HMedicaid
OK200505990HMedicaid
244522304Medicare PIN
H49420Medicare UPIN
MO209007509Medicaid