Healthcare Provider Details

I. General information

NPI: 1457375586
Provider Name (Legal Business Name): BOBBY KOSHY MUTHALALY MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/26/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2000 S WHEELING AVE STE. 510
TULSA OK
74104-5649
US

IV. Provider business mailing address

2000 S WHEELING AVE STE. 510
TULSA OK
74104-5649
US

V. Phone/Fax

Practice location:
  • Phone: 918-747-5200
  • Fax: 918-748-7517
Mailing address:
  • Phone: 918-747-5200
  • Fax: 918-748-7517

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License Number20881
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: