Provider Demographics
NPI:1689787780
Name:SODAM, BALI REDDY (MD)
Entity Type:Individual
Prefix:MR
First Name:BALI
Middle Name:REDDY
Last Name:SODAM
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:4417 W GORE BLVD
Mailing Address - Street 2:SUITE 1
Mailing Address - City:LAWTON
Mailing Address - State:OK
Mailing Address - Zip Code:73505-5978
Mailing Address - Country:US
Mailing Address - Phone:580-536-5273
Mailing Address - Fax:580-357-2423
Practice Address - Street 1:4417 W GORE BLVD
Practice Address - Street 2:SUITE 1
Practice Address - City:LAWTON
Practice Address - State:OK
Practice Address - Zip Code:73505-5978
Practice Address - Country:US
Practice Address - Phone:580-536-5273
Practice Address - Fax:580-357-8500
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-16
Last Update Date:2010-12-08
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Provider Licenses
StateLicense IDTaxonomies
OK24723207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200074670AMedicaid
OKI50032Medicare UPIN
OK245735102Medicare PIN