Provider Demographics
NPI:1922369701
Name:GEETHA B KANDIMALA MD PC
Entity Type:Organization
Organization Name:GEETHA B KANDIMALA MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:GEETHA BHAVANI
Authorized Official - Middle Name:
Authorized Official - Last Name:KANDIMALA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:580-919-5361
Mailing Address - Street 1:5606 SW LEE BLVD
Mailing Address - Street 2:302
Mailing Address - City:LAWTON
Mailing Address - State:OK
Mailing Address - Zip Code:73505-9688
Mailing Address - Country:US
Mailing Address - Phone:580-919-5361
Mailing Address - Fax:
Practice Address - Street 1:5606 SW LEE BLVD
Practice Address - Street 2:302
Practice Address - City:LAWTON
Practice Address - State:OK
Practice Address - Zip Code:73505-9688
Practice Address - Country:US
Practice Address - Phone:580-919-5361
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-06-07
Last Update Date:2012-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK26013261QM2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200447100AMedicaid