Provider Demographics
NPI:1538273958
Name:SOUTHERN OKLAHOMA KIDNEY CENTER INC
Entity type:Organization
Organization Name:SOUTHERN OKLAHOMA KIDNEY CENTER INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ABDUL
Authorized Official - Middle Name:NASIR
Authorized Official - Last Name:KHAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:580-223-8614
Mailing Address - Street 1:PO BOX 637
Mailing Address - Street 2:
Mailing Address - City:ARDMORE
Mailing Address - State:OK
Mailing Address - Zip Code:73402-0637
Mailing Address - Country:US
Mailing Address - Phone:580-223-8614
Mailing Address - Fax:580-223-2561
Practice Address - Street 1:2611 CROSSROADS DRIVE
Practice Address - Street 2:
Practice Address - City:ARDMORE
Practice Address - State:OK
Practice Address - Zip Code:73401
Practice Address - Country:US
Practice Address - Phone:580-223-8614
Practice Address - Fax:580-223-2561
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-19
Last Update Date:2024-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207RN0300X
TXK8251207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OKDN6026OtherMEDICARE RAILROAD
TXDP2512OtherRAILROAD MEDICARE TX
TX194130401Medicaid
OK200124150AMedicaid
TXDN6026OtherMEDICARE RAILROAD
OK200124150AMedicaid
OK300522359Medicare PIN