Provider Demographics
NPI:1598850331
Name:DOCTORS CLINIC OF DURANT INC
Entity Type:Organization
Organization Name:DOCTORS CLINIC OF DURANT INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:KOTESWAR
Authorized Official - Middle Name:RAO
Authorized Official - Last Name:SUREDDI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:580-924-1700
Mailing Address - Street 1:1400 BRYAN DR
Mailing Address - Street 2:SUITE 300
Mailing Address - City:DURANT
Mailing Address - State:OK
Mailing Address - Zip Code:74701
Mailing Address - Country:US
Mailing Address - Phone:580-924-1700
Mailing Address - Fax:580-924-1736
Practice Address - Street 1:1400 BRYAN DR
Practice Address - Street 2:SUITE 300
Practice Address - City:DURANT
Practice Address - State:OK
Practice Address - Zip Code:74701-2156
Practice Address - Country:US
Practice Address - Phone:580-924-1700
Practice Address - Fax:580-924-1736
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-04
Last Update Date:2010-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK11978207Q00000X
OK23224207R00000X
OK11979207VG0400X
OK261QM2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecologyGroup - Multi-Specialty
No261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical SpecialtyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100733950BMedicaid
OK200076210GMedicaid
OK100177390AMedicaid