Provider Demographics
NPI:1538364005
Name:KANG, BOBBY C (DO)
Entity type:Individual
Prefix:DR
First Name:BOBBY
Middle Name:C
Last Name:KANG
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2426 W OWEN K GARRIOTT RD
Mailing Address - Street 2:
Mailing Address - City:ENID
Mailing Address - State:OK
Mailing Address - Zip Code:73703-5221
Mailing Address - Country:US
Mailing Address - Phone:580-233-7600
Mailing Address - Fax:580-233-7661
Practice Address - Street 1:2426 W OWEN K GARRIOTT RD
Practice Address - Street 2:
Practice Address - City:ENID
Practice Address - State:OK
Practice Address - Zip Code:73703-5221
Practice Address - Country:US
Practice Address - Phone:580-233-7600
Practice Address - Fax:580-233-7661
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-15
Last Update Date:2020-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKOK2373207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100215980CMedicaid
OK100215980CMedicaid
OK900522260Medicare ID - Type UnspecifiedPROVIDER NUMBER
OKDD1186Medicare ID - Type UnspecifiedRAILROAD MEDICARE PROVIDE