Basic Information
| Provider Information | |||||||||
| NPI: | 1285636829 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WHITTAKER | ||||||||
| FirstName: | RUNAKO | ||||||||
| MiddleName: | D | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1334 N LANSING AVE | ||||||||
| Address2: | 1334 N. LANSING AVE. | ||||||||
| City: | TULSA | ||||||||
| State: | OK | ||||||||
| PostalCode: | 741065907 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9185872171 | ||||||||
| FaxNumber: | 9182956155 | ||||||||
| Practice Location | |||||||||
| Address1: | 1334 N LANSING AVE | ||||||||
| Address2: | |||||||||
| City: | TULSA | ||||||||
| State: | OK | ||||||||
| PostalCode: | 741065907 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9185872171 | ||||||||
| FaxNumber: | 9182956155 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/12/2005 | ||||||||
| LastUpdateDate: | 06/03/2008 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 21966 | OK | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 100768880I | 05 | OK | MEDICAID | 100209060B | 05 | OK | MEDICAID |