Healthcare Provider Details

I. General information

NPI: 1629247341
Provider Name (Legal Business Name): SOUTHSIDE UROLOGY CLINIC, P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/27/2008
Last Update Date: 07/25/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9817 S WESTERN AVE
OKLAHOMA CITY OK
73139-2812
US

IV. Provider business mailing address

9817 S WESTERN AVE
OKLAHOMA CITY OK
73139-2812
US

V. Phone/Fax

Practice location:
  • Phone: 405-632-4500
  • Fax: 405-632-7500
Mailing address:
  • Phone: 405-632-4500
  • Fax: 405-632-7500

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number3478
License Number StateOK
# 2
Primary TaxonomyN
Taxonomy Code261QM2500X
TaxonomyMedical Specialty Clinic/Center
License Number3478
License Number StateOK

VIII. Authorized Official

Name: RAJENDRA K MOTWANI
Title or Position: OWNER
Credential: D.O.
Phone: 405-632-4500