1598850331 NPI number — DOCTORS CLINIC OF DURANT INC

Table of content: (NPI 1598850331)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1598850331 NPI number — DOCTORS CLINIC OF DURANT INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DOCTORS CLINIC OF DURANT INC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1598850331
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/10/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1400 BRYAN DR
Provider Second Line Business Mailing Address:
SUITE 300
Provider Business Mailing Address City Name:
DURANT
Provider Business Mailing Address State Name:
OK
Provider Business Mailing Address Postal Code:
74701
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
580-924-1700
Provider Business Mailing Address Fax Number:
580-924-1736

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1400 BRYAN DR
Provider Second Line Business Practice Location Address:
SUITE 300
Provider Business Practice Location Address City Name:
DURANT
Provider Business Practice Location Address State Name:
OK
Provider Business Practice Location Address Postal Code:
74701-2156
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
580-924-1700
Provider Business Practice Location Address Fax Number:
580-924-1736
Provider Enumeration Date:
10/04/2006

Additional Information

Authorized Official

Authorized Official Last Name:
SUREDDI
Authorized Official First Name:
KOTESWAR
Authorized Official Middle Name:
RAO
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
580-924-1700

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  11978 , registered in the state of OK ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 207R00000X , with the licence number: 23224 , registered in the state of OK ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207VG0400X , with the licence number: 11979 , registered in the state of OK ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QM2500X , registered in the state of OK ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 100733950B , issued by the state of ( OK ) . This identifiers is of the category "MEDICAID".
  • Identifier: 200076210G , issued by the state of ( OK ) . This identifiers is of the category "MEDICAID".
  • Identifier: 100177390A , issued by the state of ( OK ) . This identifiers is of the category "MEDICAID".




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