Provider Demographics
NPI:1396783056
Name:ENNAMURI, KUMAR B (MD)
Entity type:Individual
Prefix:
First Name:KUMAR
Middle Name:B
Last Name:ENNAMURI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3000 N GRAND BLVD
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73107-1818
Mailing Address - Country:US
Mailing Address - Phone:405-632-6688
Mailing Address - Fax:
Practice Address - Street 1:317 E HIMES ST
Practice Address - Street 2:
Practice Address - City:NORMAN
Practice Address - State:OK
Practice Address - Zip Code:73069-7810
Practice Address - Country:US
Practice Address - Phone:405-632-6688
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-03
Last Update Date:2024-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK20474207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100018370FMedicaid
OK$$$$$$$$$WMedicare PIN
OKG68975Medicare UPIN
OK100018370FMedicaid