Provider Demographics
NPI:1497713671
Name:BACHENBERG, EARL UDO (DO)
Entity Type:Individual
Prefix:DR
First Name:EARL
Middle Name:UDO
Last Name:BACHENBERG
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 1:1844 E 15TH ST
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74104-4611
Mailing Address - Country:US
Mailing Address - Phone:918-749-7177
Mailing Address - Fax:
Practice Address - Street 1:1844 E 15TH ST
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74104-4611
Practice Address - Country:US
Practice Address - Phone:918-749-7177
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-03
Last Update Date:2008-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK1497207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100018180BMedicaid
OK100018180BMedicaid