Provider Demographics
NPI:1457375586
Name:MUTHALALY, BOBBY KOSHY (MD)
Entity Type:Individual
Prefix:
First Name:BOBBY
Middle Name:KOSHY
Last Name:MUTHALALY
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 1:2000 S WHEELING AVE
Mailing Address - Street 2:STE. 510
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74104-5649
Mailing Address - Country:US
Mailing Address - Phone:918-747-5200
Mailing Address - Fax:918-748-7517
Practice Address - Street 1:2000 S WHEELING AVE
Practice Address - Street 2:STE. 510
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74104-5649
Practice Address - Country:US
Practice Address - Phone:918-747-5200
Practice Address - Fax:918-748-7517
Is Sole Proprietor?:No
Enumeration Date:2006-07-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK20881207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
44599Medicare UPIN