Provider Demographics
NPI:1689863946
Name:COMANCHE NEPHROLOGY PC
Entity Type:Organization
Organization Name:COMANCHE NEPHROLOGY PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:BALI
Authorized Official - Middle Name:REDDY
Authorized Official - Last Name:SODAM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:580-536-5273
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:
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:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-23
Last Update Date:2010-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK24723207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200123460AMedicaid
OKI50032Medicare UPIN
OK200123460AMedicaid