Individual
DR. CHARLES BERRY FULLENWIDER
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
M.D.
Contact information
Practice address
4318 W OKMULGEE ST, MUSKOGEE, OK 74401-4648
(918) 683-1238
(918) 683-1239
Mailing address
6600 S YALE AVE STE 1400, TULSA, OK 74136-3331
Taxonomy
Speciality
Code
Description
License number
State
207T00000X
Neurological Surgery Physician
Primary
12300
OK
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
100100060A
—
OK
Enumeration date
09/20/2005
Last updated
05/01/2023
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