Healthcare Provider Details

I. General information

NPI: 1629052964
Provider Name (Legal Business Name): KUMUDINI M VAIDYA MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/30/2005
Last Update Date: 11/12/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2222 W IOWA AVE
CHICKASHA OK
73018-2738
US

IV. Provider business mailing address

PO BOX 1069
CHICKASHA OK
73023-1069
US

V. Phone/Fax

Practice location:
  • Phone: 405-224-8111
  • Fax: 405-574-7765
Mailing address:
  • Phone: 405-224-8111
  • Fax: 405-574-7765

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number12249
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: