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General NPI Number Information
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NPI Number | 1023239431
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Entity Type | Organization
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Legal Business Name | WACHITA KIDNEY AND HYPERTENSION SPECIALISTS PLLC
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Dates
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Enumeration Date | 05/01/2007
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 4417 W GORE BLVD STE 3
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City | LAWTON
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State | OK
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Zip | 73505-5978
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Country | US
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Telephone | 580-357-1002
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 7227
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City | LAWTON
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State | OK
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Zip | 73506-1227
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | CEO
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Name | DR. RAPHAEL LOUTOBY
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Credential | MD
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Telephone | 580-357-1002
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207RP1001X
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Taxonomy Name | Pulmonary Disease Physician
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License Number | 25397
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License Number State | OK
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