Provider Demographics
NPI:1548688757
Name:WITTROCK, ROBERT (DO)
Entity type:Individual
Prefix:MR
First Name:ROBERT
Middle Name:
Last Name:WITTROCK
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1919 S WHEELING AVE
Mailing Address - Street 2:STE 304
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74104-5632
Mailing Address - Country:US
Mailing Address - Phone:918-794-7337
Mailing Address - Fax:918-794-7338
Practice Address - Street 1:1919 S WHEELING AVE
Practice Address - Street 2:STE 304
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74104-5632
Practice Address - Country:US
Practice Address - Phone:918-794-7337
Practice Address - Fax:918-794-7338
Is Sole Proprietor?:No
Enumeration Date:2014-04-03
Last Update Date:2019-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK6277208000000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program