Provider Demographics
NPI:1043411283
Name:MUCKALA, ERICH H (DO)
Entity type:Individual
Prefix:
First Name:ERICH
Middle Name:H
Last Name:MUCKALA
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:4500 S GARNETT RD
Mailing Address - Street 2:STE 300
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74146-5229
Mailing Address - Country:US
Mailing Address - Phone:918-728-6194
Mailing Address - Fax:918-664-0267
Practice Address - Street 1:4500 S GARNETT RD
Practice Address - Street 2:STE 300
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74146-5229
Practice Address - Country:US
Practice Address - Phone:918-728-6194
Practice Address - Fax:918-664-0267
Is Sole Proprietor?:No
Enumeration Date:2007-05-29
Last Update Date:2012-04-03
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
OH58.0020322085R0202X
OK50232085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH58.002032OtherTRAINING LICENSE
OK5023OtherSTATE MEDICAL LISCENSE