Provider Demographics
NPI:1710120167
Name:NACOGDOCHES NEPHROLOGY, PA
Entity Type:Organization
Organization Name:NACOGDOCHES NEPHROLOGY, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:NEPHROLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:DOLAMU
Authorized Official - Middle Name:O B
Authorized Official - Last Name:SOKUNBI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:936-552-7216
Mailing Address - Street 1:626 RUSSELL BLVD
Mailing Address - Street 2:SUITE B
Mailing Address - City:NACOGDOCHES
Mailing Address - State:TX
Mailing Address - Zip Code:75965-1246
Mailing Address - Country:US
Mailing Address - Phone:936-552-7216
Mailing Address - Fax:936-552-7274
Practice Address - Street 1:626 RUSSELL BLVD
Practice Address - Street 2:SUITE B
Practice Address - City:NACOGDOCHES
Practice Address - State:TX
Practice Address - Zip Code:75965-1246
Practice Address - Country:US
Practice Address - Phone:936-552-7216
Practice Address - Fax:936-552-7274
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-04-15
Last Update Date:2009-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ7203174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX113679803Medicaid
TX113679803Medicaid